Martine Kruijtbosch

38 Chap t e r 2 .1 Dispensing without a prescription Patients regularly requested (restricted) medicines without a (valid) prescription. In these situations, pharmacists had to balance the necessity and risks of dispensing. Pharmacists felt it hard to make this balance because they had insufficient clinical information and were reluctant to deviate from laws and regulations. PHARM-71: The middle-aged son of an elderly patient visited the pharmacy just before closing time. He showed a picture on his mobile phone of an oxycodone prescription for his father who had just been discharged from hospital. He said his father suffered from severe pain and he could not get the real prescription in time before the pharmacy closed. ‘ The prescription does not comply with the law but this patient could suffer unnecessarily if I don’t dispense .’ Quality defects These moral dilemmas were related to uncertainty about the quality of a pharmaceutical product and the risks of dispensing a product that might be ineffective or harm patients. PHARM-309: A patient visited the pharmacy with three golimumab injections worth €3500 which had been outside the refrigerator for about 1 day. ‘ The manufacturer told me they expected no quality issues but could not give any guarantee .’ The pharmacist doubted whether the patient would be harmed by using the injections, and felt that, given their cost, discarding the injections was not socially responsible. DISCUSSION This study presents moral dilemmas experienced by community pharmacists in clinical practice. The underlying themes address the challenges pharmacists face while providing care in a complex setting with economic and legal constraints, demanding patients and limited professional autonomy. Analysis showed that most moral dilemmas concerned the relationship between pharmacists, patients and physicians. This is not surprising considering that pharmacists are responsible for helping patients achieve positive health outcomes, and this responsibility requires that they work with patients and other health professionals. 49 As far as we know, no previous study used narratives to understand the moral dilemmas that pharmacists experience in clinical practice. 26, 29, 40 Writing a narrative shortly after a dilemma occurred avoids recall problems and enables pharmacists to reflect directly on their feelings. Previous studies generally interviewed pharmacists and asked them to recall dilemmas that occurred in the past. 29, 40 This may be the reason why, in those studies, pharmacists mainly