Martine Kruijtbosch

186 Chap t e r 5 without a prescription’ showed that pharmacists felt it hard to make a choice because they had insufficient clinical information and were reluctant to deviate from laws and regulations. But overall the moral dilemma narratives gave the impression that the pharmacists were more concerned about the patient’s well-being and the mutual trust in the treatment relationship than about breaking the law (Chapter 2.1). This tendency was confirmed in situations of drug shortages. Dutch community pharmacists’ moral intentions in situations of drug shortages (i.e. reflected in the ranking of the moral reasoning considerations in the handling of the drug shortage scenarios [Chapter 3.2]) were based on a rules and regulation perspective as well but the moral intentions based on a professional ethics perspective were more dominant (Chapters 3.2 and 3.3). An explanation may be that Dutch community pharmacists have a strong professional relationship with primary care physicians 89,90 and are professionally more autonomous than community pharmacists in other countries. Their social role is comparable with the role of clinical pharmacists in many other countries. 91,92 Also, Dutch community pharmacists are legally recognised as health professionals and share the responsibility for drug therapy of their patients with physicians according to the Dutch Medical Treatment Agreement Act (WGBO). This law became applicable for community pharmacists in 2007. Moreover, since 2016 community pharmacy is recognised as an official specialisation, thereby giving a similar status to the profession as general practitioners and other medical specialists. Dutch community pharmacists may therefore be regarded more as health professionals with thereto granted professional autonomy than that is the case in some other countries. Moral reflectivity in dialogue The challenge of decision-making in healthcare practice is managing uncertainty. 93 It is for health professionals essential to view uncertainty as a productive component of clinical reasoning. All clinical judgements require moral reflection since professional values always play a role. Each uncertainty may be an opportunity for new insights and may ultimately improve patient care. In any case, finding solutions requires moral sensitivity and reasoning, but even more so moral intention and courage from pharmacists to be prepared to endure that uncertainty till it is resolved in a best possible way for the patient. Providing health professionals with ethical guidelines only is not enough. 94 Ethical competencies need to be trained. Professional ethics education aims to train health professionals to internalise the professional values, overcome concerns, build moral intention and courage, and as such to develop a professional identity. An education method that has proven to be successful in developing ethical competencies among secondary care professionals is moral case deliberation (MCD). 95- 97 During MCD health professionals systematically and jointly reflect on a moral dilemma. Although we have not come across studies which have explored and described MCD with