Martine Kruijtbosch

61 Pro f es s i ona l va l ues wi t h i n mo ra l d i l emmas moral distress, pharmacists could proactively make agreements to refer patients in need of euthanasia to other pharmacists who have no such convictions. Conflicting values and moral distress also occur among other health professions. Unfortunately, effective strategies to deal with moral distress have not yet been developed. 34 The customised core value reliable and caring reflects that pharmacists not only felt a responsibility for the quality of pharmaceutical products, but also a responsibility to foster their professional relationships both with patients and other health professionals. It has previously been identified that the health professional-patient fiduciary therapeutic relationship 9,35,36,37 as well as effective collaboration with other health professionals 38,39 are essential to (pharmaceutical) healthcare and can improve its services. However, aiming to care simultaneously for both these relationships often leads to moral dilemmas. 30 The moral dilemmas in this study illustrate the complexity of the core value responsibility to society . The philosophy behind the current Dutch healthcare system is based on well- known international principles: access to care for everyone, solidarity through an obligatory and accessible health insurance policy for all and good quality of care. The spending on pharmaceuticals is on the lower end of European and other Western countries. Pharmacists are expected to contribute to the sustainability of access to medicines by advising prescribers on cost-effective prescribing and generic substitution of expensive specialties as much as possible. In some of the narratives, pharmacists are confronted with costs that will affect the sustainability of the pharmacy in such a way that guaranteeing access to pharmaceutical care for other patients will be endangered. For example, pharmacists reflect on the option to no longer freely dispense medication to patients who repeatedly cannot pay for expensive medication or on the decision to deliver additional care activities that are not reimbursed. The financial concerns/ business pressure have been reported by several studies. 2,31 However, the narratives in our study did not obviously show commercial behaviour. For example, we did not come across narratives wherein pharmacists described situations in which they were more focused on selling (more expensive) products than trying to provide the best pharmaceutical care to patients. Pharmacists, like all other health professionals, need to distinguish between healthcare practice values and business values. For pharmacists in community pharmacy, this may even be more complex, as the public often perceives them as ‘shopkeepers’. For example, when a pharmacist proposes an elderly patient to start gastro- protection because the patient receives an NSAID, the patient can perceive this proposal as a ‘selling practice’ by the pharmacist. However, this proposal is in accordance with clinical guidelines and pharmacists’ responsibility towards the patient (prevention of stomach bleeds) as well as to society (prevention of the costs of hospitalisation).