Martine Kruijtbosch

96 Chap t e r 3. 2 Drug shortages require advanced levels of professionalism, such as a high level of pharmaceutical expertise, strong communication and collaboration skills 11,19 and advanced levels of moral reasoning. In situations that present moral dilemmas, moral reasoning entails reflection on whose and which values are at stake for any possible course of action and how professional decisions may influence patients’ well-being. 23-25 Moral reasoning can be defined as deliberating about what a person ought, morally, to do, a species of practical reasoning. 26 Ethical reasoning is used in the same sense but is oftenmore concernedwith cognitive processes that persons follow in making a decision prior to behavior. 27 Ethical reasoning is therefore mostly used with respect to special fields of interest, e.g. business ethics, clinical ethics, etc. Throughout this paper the term moral reasoning is used, which can also be read as ethical reasoning. In the moral reasoning literature three developmental levels of moral reasoning perspectives (schemas) are recognised based on Kohlberg’s cognitive moral development theory 28 : a pre-conventional level (reasoning focused on personal interest), a conventional level (reasoning focused on maintaining norms) and a post-conventional level (reasoning focused on universal principles, beyond personal interest and norms). Rest et al 29 developed these three moral reasoning perspectives as a response to Kohlberg’s claim of six sequential cognitive stages where one moves as on a staircase one stage at a time (Table 1). Rest et al defined moral development more as a gradual shift from lower to more complex conceptions of how to organize society-wide co-operation. In their theory moral reasoning perspectives are more contextual and automatic and less reflective than Kohlberg’s six stages, and are at any moment available to the individual. 30 An extensive comparison between the two models is described elsewhere. 28,31,32 In the view of Rest et al moral reasoning perspectives (MRPs) are tacit beliefs and cognitions present in a person’s long-term memory of which he or she is not explicitly aware. 28,31-33 These tacit beliefs and cognitions help individuals understand new information based on prior experiences. 30 Rest et al developed thereto a moral reasoning test, the Defining Issues Test (DIT), that is able to activate a person’s tacitly preferred perspective when a person reads written statements that represent these MRPs. 33 People rate and rank their tacitly preferred MRP statements more highly when making decisions. 31,33 Pharmacists’ moral reasoning has been previously studied, both without the DIT 34-36 and with the DIT. 28,32,37-40 The results of these latter studies suggest that pharmacists score low on post-conventional moral reasoning compared to other health professionals. 38 However, a recent study suggested that an educational intervention aimed at improving moral reasoning competencies, positively affected the development of these competencies in pharmacists as measured with the DIT. 41 To date, research on drug shortages in community pharmacy has focused on the nature, extent and impact of these shortages on patients and pharmacists and on causes of and solutions to