Martine Kruijtbosch

39 Mo ra l d i l emmas o f commun i t y pha rmac i s t s recalled dilemmaswith a high legal impact. For example, pharmacists expressed fear of breaking the law when a patient asked for a controlled drug without a (valid) prescription. 26, 29, 40 When legal issues occurred in this study, pharmacists were more concerned about the patient’s well- being and the mutual trust in the treatment relationship than about breaking the law. Pharmacists experienced dilemmas during their professional contacts because the behaviour of patients and physicians made it difficult for them to act autonomously, according to their professional core values. 50 Since the days of Hippocrates, health professionals’ core value is not to harm patients and to act in their best interest. However, conflicts may arise when more than one health professional aims to act according to that value. The degree of professional autonomy of an individual health professional depends on the extent to which other health professionals grant that autonomy. 51 Regular collaboration between pharmacists and other health professionals may promote mutual trust and respect for each other’s knowledge and expertise. 52-54 Pharmacists’ autonomy may also be challenged because pharmacists are often the last link in a multidisciplinary care chain, e.g. in end - of - life pharmaceutical care issues. In that position pharmacists’ expertise comes into play too late or is not recognised. 55, 56 Pharmacists in these situations described that their expertise was disregarded and that they were expected to dispense only. These moral dilemmas demonstrate that pharmacists need more training to convince physicians of their expertise. The professional autonomy of pharmacists may also be restricted by patients or parties such as insurance companies or the health inspectorate. Patients may also consider physicians to have more authority than pharmacists. This can sometimes lead to claiming and/or aggressive behaviour of patients. This behaviour undermines the trust relationship between the pharmacist and the patient. This resembles healthcare consumerism, which is reported to challenge the ability of health professionals to optimally fulfil patients’ and societal needs. 9-14 Dilemmas under the theme ‘public health policy and third-party payer regulations ’ showed that health insurance companies can also undermine pharmacists’ autonomous professional decision-making and actions. Insurance companies oblige pharmacists to replace expensive branded drugs with cheaper generics. Although pharmacists do not object to dispensing cheaper medicines whenever possible, this responsibility also disturbed their relationship with patients who strongly objected to generics. This finding confirms a worldwide trend that economically motivated health policies challenge the professional autonomy of all health professionals. 12-14,17,18 Health policy makers should realise that weakening health professionals’ autonomy, for example due to reimbursement policies, may negatively affect patients’ trust in healthcare. 19