Martine Kruijtbosch

187 Gene ra l d i s cu s s i on pharmacists, studies exist that made mention of reflectionmethods such as moral dilemma case discussions. These studies showed positive effects regarding the development of pharmacists’ and pharmacy students’ ethical decision-making processes. 18,20,98,99 Our study regarding MCD (Chapter 4) showed that this method of joint reflection has potential to foster community pharmacists’ moral reflectivity. Moreover, our results indicate that MCD may help pharmacists to further increase sensitivity for the moral dimension of decision-making, and to enhance reflection on and commitment to professional values (moral sensitivity, reasoning and motivation). Pharmacists who participated in the MCD sessions learned from each other’s views regarding the perspectives of the parties involved in the dilemma and their moral judgements and intentions how to deal with the dilemma. The deliberation increased their awareness of the professional values underneath their reasoning. Pharmacists were generally less consciously aware of these values before participating in these MCD-sessions as care decisions in daily practice are often made on the basis of their gut feelings. 50,51 The MCD method should be explored further in the context of the development of ethical competencies of community pharmacists, both qualitatively as well as quantitatively. Besides, methods should be developed to measure outcomes of MCD with pharmacists. A recent study has developed such a method for MCD with health professionals working in secondary healthcare institutions. 100 Recommendations for education, practice, policy and research We demonstrated that community pharmacists experience a diversity of moral dilemmas in their daily pharmacy practice. We argued that community pharmacists need moral reflection in the processes of moral sensitivity, reasoning and intention to cope with these moral dilemmas. In this final section, we give recommendations to improve the ethical decision- making processes of pharmacists. Although we specifically studied the ethical decision- making of community pharmacists, we are of the opinion that these recommendations apply for pharmacists in general, especially those with clinical roles. Pharmacists should be more aware that moral dilemmas arise mostly in their professional relationships and often when their professional autonomy is challenged by the behaviour of patients and other health professionals. Pharmacists should use their professional values to better recognise and reflect on the moral dilemmas in practice (Chapters 2.1 and 2.2). Moral reasoning tests for pharmacists can be used to monitor the moral reasoning perspective (MRP) of pharmacists in general and in specific situations such as in case of drug shortages (Chapter 3.2 and 3.3). Moral case deliberation (MCD) sessions can aid community pharmacists to develop moral reflectivity to make appropriate pharmaceutical care decisions in daily practice (Chapter 4).