RxCe - Ethics in Pharmacy Practice Materials

ETHICS IN PHARMACY PRACTICE

WILLIAM COOK, PhD

William Cook is a licensed psychologist who worked for 15 years in private practice in Montana. He earned his doctorate degree from Texas A&M University.

Topic Overview

In the pharmacy setting, pharmacists and pharmacy staff may be guided by the Code of Ethics for Pharmacists and the principles embodied in the Oath of a Pharmacist. Ethics can be divided into three categories: metaethics, normative ethics, and applied ethics. Beauchamp and Childress built on the ethical theory called principlism. They describe four principles that are foundational to ethics in biomedicine: autonomy, non-maleficence, beneficence, and justice. Confidentiality may be added as a fifth foundational principle. Principlism is attractive because of its simplicity but its simplicity has been challenged by an idea known as ethical pluralism, which posits that norms are not necessarily universal but can be diverse. The principles underlying ethics in medical practice benefit patients. They lead to patient-centered care, which leads to improved patient care and outcomes. The principle of beneficence is not universally part of ethical standards in other professions. It promotes patient-centered care and empathy in the patient-clinician relationship. Non-maleficence calls on clinicians not to harm a patient. Ethics in medical practice can foster patient safety.

Accreditation Statement:

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is

Pharmacist 0669-0000-23-020-H03-P

Pharmacy Technician 0669-0000-23-021-H03-T

Credits: 1 hour of continuing education credit

Type of Activity: Knowledge

Media: Internet Fee Information: $4.99

Estimated time to complete activity: 1 hour, including Course Test and course evaluation

Release Date: February 27, 2023 Expiration Date: February 27, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From February 27, 2023, through February 27, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures.”

Study the section entitled “educational activity.”

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Define ethics and describe how it differs from morality and legality

Define ethics and discuss parts of the pharmacy code of ethics

Discuss why ethics is important to patient care

Recognize common ethical dilemmas when dispensing drugs or providing drug information

Disclosures

The following individuals were involved in the development of this activity: William Cook, PhD, and Susan DePasquale, MSN, PMHNP-BC. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.

Introduction

Ethics consists of a set of principles or rules of conduct that emerge from moral standards. In the broad sense, ethics is applied to many situations or relationships in life. When it comes to healthcare, ethics emerges within the context of patient care, i.e., what a healthcare professional should do when providing healthcare, and how the presence or absence of ethical conduct impacts patient care and outcomes. In the pharmacy setting, pharmacists and pharmacy staff may be guided by the Code of Ethics for Pharmacists and the principles embodied in the Oath of a Pharmacist.

The Development of Ethical Standards

Varkey (2021) describes ethics as “a broad term that covers the study of the nature of morals and the specific moral choices to be made.”1 Thus, ethics includes an accepted set of principles or rules of conduct that people use, or should use, to govern their choices in their day-to-day lives and interactions with others; but how do ethical standards or codes of ethic form? This can be studied by looking at the different branches of ethics and asking how societal norms are created, and what foundations, concepts or values underlie societal norms.

Branches of Ethics

Ethics can be divided into three categories: metaethics, normative ethics, and applied ethics.1-3

Metaethics

Metaethics looks at morality and considers how morality forms.1,2 Metaethics questions the psychological factors, presuppositions, practices, and reasoning behind morality. Metaethics asks if morality is subjective or based on some objective truth. Metaethics also probes the connection between moral standards of human conduct.1,2 In this context, a distinction may be made between morality as a choice versus what a person must or ought to do.

Normative Ethics

Normative ethics studies the “norms” that make up ethical rules.1-3 These principles guide a person so he or she does the right thing in certain circumstances, or does what is considered good. These are often mirrored in professional oaths and codes of ethics.

Applied Ethics

Applied Ethics considers how ethical standards are applied in real-world situations.1-3 When applying an ethical standard, moral questions often arise. For example, a physician takes an oath to “First, do no harm,” and then is asked to assist a patient in dying (euthanasia). Is this moral? Is it ethical?4

Societal Norms and Principlism

As stated above, normative ethics studies the “norms” that make up ethical rules but how do rules regarding human conduct become a norm? And, what values underpin the evolution of these rules?

Biomedical ethics differs somewhat from general ethics, so in order to answer these questions within medicine, a review of normative, biomedical ethics begins with the seminal work of Beauchamp and Childress.5,6 In more recent years, scholars have questioned the approach of Beauchamp and Childress and considered divergent views but Beauchamp and Childress’ work is still widely used and considered when discussing biomedical ethics.

Beauchamp and Childress built on the ethical theory called principlism.6 Principlism in biomedical ethics is best described as ethics based on foundational principles that are universal. Beauchamp and Childress describe four principles that are foundational to ethics in biomedicine: autonomy, non-maleficence, beneficence, and justice.6 These four principles form the “societal norms” that identify what a healthcare professional should do or what is good.1,6,7 Beauchamp and Childress argue that from these principles come a “common morality” made up of the “norms about right and wrong human conduct that are so widely shared that they form a stable social compact”6 The use of the word “common” implies that this morality is universal and applicable to everyone. For

example, the rule that a person should not steal from a neighbor, or should not harm another person, is universal; these norms are not individual or applicable only in certain situations but are commonly regarded as the standard.6,7

Empirical evidence supports the position that healthcare professionals are guided by autonomy, non-maleficence, beneficence, and justice.6 Moreover, the strength of principlism lies in its perceived societal consensus (universality).7 (Some scholars add an additional principle, confidentiality - respecting and protecting patient information - which will also be discussed below.)1 It is believed here that when a person is confronted with an ethical decision, “appealing to norms of the common morality” produce the best results.7

Autonomy

The ethical principle of autonomy is based on the premise that every person has intrinsic, unconditional worth, and should make his or her decisions or moral choices.1 Informed consent is essential to patient autonomy. Informed consent can be given by a patient who is competent and who receives full disclosure, comprehends the disclosure, and can act voluntarily.1

Non-maleficence

Non-maleficence is the principle that a healthcare professional should not cause harm to a patient. It embodies the Hippocratic Oath:1 “Primum non nocere,” translated, “First, do no harm.”8

Beneficence

Beneficence obliges a healthcare clinician to act for the benefit of the patient, to protect and defend patient rights, prevent harm, and remove conditions that may cause harm.1

Justice

Justice is understood as the fair and equitable treatment of others. In medical ethics, justice refers to fair access to healthcare, or health equity.1

Confidentiality

With some exceptions, healthcare clinicians are obligated to keep patient medical information confidential, and not disclose it without the patient's prior permission.1

Societal Norms and Ethical Pluralism

Principlism is attractive because of its simplicity but its simplicity has been challenged by an idea known as ethical pluralism, which posits that norms are not necessarily universal but can also be diverse. Pluralism leads to questions regarding whether principlism can direct moral decision-making in a clinical setting since it does not take into account cultural differences or emotional and personal factors.7 Principlism may not reflect the ethical decision-making process in clinical practice, and it does not guide actions sufficiently or explain how professional integrity can be obtained.7 Christen, et al. (2014) provide an example of this from Westra, et al. (2009).9 Westra, et. al., explored Beauchamp and Childress’ four principles and their application within Islamic culture.9 They found that when it comes to the application of these principles, the decision-making process and conclusions reached can be quite different depending on a person’s cultural starting point.9 This emphasizes the importance of cultural competency within healthcare.

In addition to cultural differences, theorists are more readily acknowledging that “morality is not monolithic” and that human culture is not static.10 Earlier theories on morality were more rationally-based but this has been changing. There is a trend away from rationalism toward emotional and intuitive moral judgment, which impacts perceived morality and the norms that influence codes of ethics.10 As norms change, people may still value past principles but may not necessarily apply them when making ethical decisions. An example of this could be Page (2012) who found that psychology students value the principles but do not actually seem to use them directly in the decision- making process, which partly calls into question their practical relevance.7,11

This has given rise to approaches such as Moral Foundations Theory (MFT). In MFT, automatic and intuitive emotional reactions that exist in moral evaluation across cultures were expressed within five psychological foundations: Harm,

Fairness, Ingroup, Authority, and Purity.10 The direction a person will go in making moral decisions will depend on the psychological foundation a person uses or emphasizes more.10 For example, a person who is more focused on purity will make different moral decisions than a person more focused on fairness. Different moral foundations do not lead to the societal consensus found with Beauchamp and Childress’ principlism; instead, they can lead to distinct, different outcomes, which may be reflected in major societal conflicts or other societal changes.10

Ethics in Medicine Should be Patient-Centered

The focus of biomedical ethics needs to be patient-centered and promote positive patient outcomes.12,13 Erstad (2022) reviewed research on ethics related to pharmacy practices and found that researchers listed “fair dealing and equity, patient-centered care, and faithfulness as virtues common to practicing pharmacists.”12 This is reflected in the Pharmacists’ Patient Care Process (PPCP) document approved in 2014, which was incorporated into the accreditation standards of the Accreditation Council for Pharmacy Education (ACPE).12 “One of the stated goals of the process is to provide a comprehensive approach to team- based, patient-centered care.”12

Erstad (2022) points out that the ACPE accreditation standards do not expand on ethics in the PPCP and argues that a more explicit approach to utilizing ethical decision-making in this process is needed.12 Thus, the Code of Ethics for Pharmacists should play a more prominent role in PPCP.12

Codes of Ethics and Oaths

The patient-centered approach to biomedical ethics is reflected in the codes of ethics and oaths. A code of ethics or oath is a guide, and not necessarily a mandatory law.14,15 Codes of ethics and oaths often emphasize revised versions of the principles of Beauchamp and Childress - autonomy, non- maleficence, beneficence, and justice.16 As mentioned above, confidentiality is also regarded as an important principle.1,16

The American Pharmacists Association (APhA) has published the Code of Ethics for Pharmacists.14,15 The Code of Ethics for Pharmacists may be obtained from APhA at https://www.pharmacist.com/Code-of-Ethics.15

The Code begins with tenet I by describing the pharmacist-patient relationship as a covenant.14,15 A covenant evokes promises or obligations a pharmacist must do when caring for a patient in exchange for the “gift of trust” the patient has placed in the pharmacist.15 However, this tenet may be more of an “ideal” a pharmacist should strive for in day-to-day practice, rather than a description of the relationship.14

As mentioned above, codes of ethics often include principles of autonomy, non-maleficence, beneficence, justice, and confidentiality. The Code of Ethics for Pharmacists is no different.15 For example, tenet II embodies beneficence and confidentiality: “A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.”15 (Italics added.) Tenet III promotes patient autonomy: “A pharmacist respects the autonomy and dignity of each patient.”15 (Italics added.) Tenets IV and V describe a form of non-maleficence: “IV. … A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients,”15 and “V. A pharmacist maintains professional competence.”15 Finally, a pharmacist seeks justice: “VIII. A pharmacist seeks justice in the distribution of health resources. When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society.”15

Ethical standards are also reflected in the oath professionals may take at the beginning of their careers.17-19 The Oath of a Pharmacist may be obtained from APhA at https://www.pharmacist.com/About/Oath-of-a-Pharmacist. A pharmacist “will promote inclusion, embrace diversity, and advocate for justice to advance health equity[;] assure optimal outcomes for all patients[; and,] respect and protect all personal and health information entrusted to [the pharmacist].”19

These principles and standards provide guidance for appropriate ethical and professional behavior.15,19 This means that a pharmacist’s conduct is not only guided by the Code and Oath on ethical conduct toward patients but toward

colleagues and coworkers.15,19 For example, tenet VI states that “[a] pharmacist respects the values and abilities of colleagues and other health professionals.”15

Some ethical rules may be codified into law, making them “mandatory,” and raising the specter of potential criminal or administrative consequences. An example of this would be the ethical principle of “First, do no harm.” In some cases, if a professional harms a patient, criminal consequences may result if the harm were intentional, or a loss of a professional license may result if the harm were caused by negligence.

Why Ethics is Important to Patient Care

The principles underlying ethics in medical practice benefit patients.16,20 They lead to patient-centered care, which leads to improved patient care and outcomes.12 The principle of beneficence is not universally part of ethical standards in other professions. It promotes patient-centered care and empathy in the patient-clinician relationship.20 Empathy is integral to building trust between the patient and the healthcare professional.20 Non-maleficence calls on clinicians not to harm a patient.20 The practical application of non-maleficence requires a clinician to make a benefits-risks analysis before recommending a treatment.1 Ethics in medical practice can foster patient safety; for example, in the pharmacy setting, ethical decision-making is instrumental to prescription drug safety.21

Ethics in medical practice also improves the outlook of healthcare professionals, leading to higher job satisfaction and less professional burnout.16 It also promotes respect between colleagues and coworkers. These working together culminate in better patient-clinician relationships, patient outcomes, and working environments.

Ethical Considerations in Clinical Practice

Ethical decisions are made daily in clinical practice. A clinician may be confronted with ethical dilemmas, especially when any of the moral principles underlying bioethics come into conflict.1 In other cases, special circumstances may make ethical decision-making more difficult.5 A few examples will be discussed here.

Beneficence and Autonomy

A healthcare provider must act for the benefit of the patient but what does a provider do if the patient, exercising autonomy, makes a treatment choice that will not benefit the patient, or will even do harm? Should the clinician take on a paternalistic role and make the healthcare decision for the patient?7 Should patients with varying degrees of dementia be given some level of autonomy?5 These questions, and other related questions, can create a dilemma for a clinician. As mentioned above, patient autonomy requires that the patient possess the mental competency to understand the disclosures made to the patient by the clinician.1

An ethical dilemma can become even more pronounced when a minor child is involved. Kruijtbosch, et al. (2018) provided an example of a mother who requested paracetamol (acetaminophen) for her 1-year-old baby who had a high fever for a week.22 The pharmacist believed that the treatment preference of the mother was not supported by evidence-based medicine or professional guidelines and that the treatment could be ineffective or harmful. In this situation, a pharmacist reported, “I tried to convince her to consult her [primary physician] as her baby might have a dangerous infection. She didn’t agree. Her attitude frustrated me. I want to do what is best for the baby, but at the same time have to respect the mother’s decision.”22

Autonomy and Confidentiality

Situations can arise where a pharmacist believes it is in the patient’s best interest to share the patient’s medical information even though the patient refuses to give consent or even requests that the information not be disclosed.22 In another example by Kruijtbosch, et al., a female patient who is being treated for bipolar disorder told her pharmacist that she wanted to discontinue her prescription for mirtazapine. She expressly told the pharmacist not to notify her psychiatrist. The pharmacist “... explained to her that [he] couldn’t provide proper pharmaceutical counseling because [he] didn’t have relevant background information.” The pharmacist wanted to respect the patient’s confidentiality and autonomy but he felt it was in the patient’s best interest to notify her psychiatrist.22

Ethical Decision-making

Varkey (2021) gives an ethical dilemma in a case where two patients arrive in the emergency department with respiratory illnesses.1 Both patients test positive for COVID-19. One patient is a 74-year-old woman who resides in an assisted living facility. She has shortness of breath and malaise, among other conditions. The other patient is a 22-year-old male who has had flu-like symptoms for a week, which become progressively worse.1

At the time the patients enter the emergency department they are both in respiratory failure and both are in urgent need of intubation and mechanical ventilation; however, there is only one ventilator available at the time. Who should be given the ventilator?1 This scenario is complicated by the presence of a pandemic, which may give rise to slightly different rules. Moreover, this dilemma is particularly critical because it involves a life-or-death decision for patients. Varkey states that “[p]riorities need to be established ethically and must be applied consistently in the same institution and ideally throughout the state and the country.”1 The social norm is that everyone should be treated equally. This decision may also be driven by “maximizing benefits.”1 However, should maximizing benefits be measured “in lives saved or in life-years saved”?1

Ethical decision-making may not only be challenging because of difficult ethical questions, as above, but also because of the realities of professional practice. For example, ethical considerations may be overlooked because the pharmacist is in a high-volume community pharmacy setting, where the pharmacist and staff lack the time or workspace to fulfill their ethical obligations.21

Ethics and Technology

New technologies can raise new questions about ethics in the medical profession. These are especially seen with new and advancing technologies such as telehealth, social media, and the digitization of medicine. Of particular importance is the impact of new technologies on empathy within the patient- clinician relationship. As mentioned above, the core principle of beneficence promotes empathy in the patient-clinician relationship so ethical concerns arise when empathy is diminished by technology.

Rothstein (2010) considered the impact modern medicine and technology have had on the Hippocratic Oath. Rothstein argued that even with technological advances, healthcare clinicians should remain obliged to respect their patients’ choices regarding information disclosure. They should preserve the confidentiality of patient information that has been entrusted to them and disclose information only in accordance with the law and prior agreements with their patients.23

One example of how technological change is accompanied by ethical concerns is in the growing telehealth field.3,24-26 The growth of telehealth during the COVID-19 pandemic required changes in HIPAA confidentiality rules to cope with the nationwide public health emergency.24 Nittari, et al. (2020) argue that even in the face of a pandemic, patient information must be protected, and informed consent respected.25

Social media has also created ethical dilemmas. These issues concern not only interactions with patients and the protection of patient confidentiality, but also interactions between colleagues and coworkers.26

Technology has also impacted empathy within the patient-clinician relationship.26 Empathy on the part of a healthcare provider is recognized as vital to patient care and the patient-provider relationship.27 Its presence has a positive effect on a patient’s satisfaction, a practitioner’s ability to treat the patient, and the patient’s health outcome.27 On the other hand, the absence of empathy can have an expected negative impact on patient care. Empathy may be disrupted during digital, telepharmacy consultations.27 Digital platforms allow a person “to instantly share thoughts, feelings, and behaviors with the rest of society … in mere seconds, often without the empathetic social filter that accompanies traditional communications.”27 Digital communications may not provide the parties engaged in conversation with the emotional signals and cues they experience when communicating face to face. This can cause the interaction to be more impersonal, leading to a “disinhibition effect,” an effect that can lead people in digital conversations to be unempathetic, hostile, or intimidating.27

The disinhibition effect is not only relevant to the patient-clinician relationship but it can affect peer relationships. Pharmacists and pharmacy staff must be careful not to interact with each other or their colleagues in

unempathetic, hostile, or intimidating tones when communicating in digital conversations. As said above, tenet VI states that “[a] pharmacist respects the values and abilities of colleagues and other health professionals.”15 Pharmacists and pharmacy staff must act with respect toward one another and display professionalism when communicating in digital conversations.

In response to the disinhibition effect, Terry and Cain (2016) refer to “digital empathy,” which is defined as the “traditional empathic characteristics such as concern and caring for others expressed through computer-mediated communications.”27 They recommend that digital empathy should be taught and practiced. This can help pharmacists and pharmacy staff avoid the disinhibition effect digital communications may give rise to.27

Summary

Ethics can be divided into three categories: metaethics, normative ethics, and applied ethics. Metaethics looks at morality and considers how morality forms. Normative ethics studies the “norms” that make up ethical rules. Applied Ethics considers how ethical standards are applied in real-world situations.

Biomedical ethics differs somewhat from general ethics, so in order to answer these questions within medicine, a review of normative, biomedical ethics begins with the seminal work of Beauchamp and Childress. In more recent years, scholars have questioned the approach of Beauchamp and Childress and considered divergent views but Beauchamp and Childress’ work is still widely used and considered when discussing biomedical ethics.

Beauchamp and Childress built on the ethical theory called principlism. They describe four principles that are foundational to ethics in biomedicine: autonomy, non-maleficence, beneficence, and justice. In medicine, the guiding principles are autonomy, non-maleficence, beneficence, and justice. Some scholars add an additional principle, confidentiality. These principles form the “societal norms” that identify what a healthcare professional should do or what is good.

Principlism is attractive because of its simplicity but its simplicity has been challenged by an idea known as ethical pluralism, which posits that norms are not necessarily universal but can also be diverse. In addition to cultural differences, theorists are more readily acknowledging that “morality is not monolithic” and that human culture is not static. The focus of biomedical ethics needs to be patient-centered and promote positive patient outcomes

The patient-centered approach to biomedical ethics is reflected in the codes of ethics and oaths. A code of ethics or oath is a guide, and not necessarily a mandatory law. Codes of ethics and oaths often emphasize revised versions of the principles of Beauchamp and Childress - autonomy, non-maleficence, beneficence, and justice. As mentioned above, confidentiality is also regarded as an important principle.

The principles underlying ethics in medical practice benefit patients. They lead to patient-centered care, which leads to improved patient care and outcomes. The principle of beneficence is not universally part of ethical standards in other professions. It promotes patient-centered care and empathy in the patient-clinician relationship. Non-maleficence calls on clinicians not to harm a patient. Non-maleficence embodies the Hippocratic Oath, calling on clinicians not to harm a patient deliberately. Ethics in medical practice can foster patient safety.

Ethics in medical practice also improves the outlook of healthcare professionals, leading to higher job satisfaction and less professional burnout. This culminates in better patient-clinician relationships and patient outcomes.

Course Test

Ethics may be described as

mandatory laws that carry criminal penalties.

the study of the nature of morals and the specific moral choices to be made.

esoteric principles that are interesting but not relevant to day-to-day moral choices.

the study of societal conflicts or other societal changes.

considers how ethical standards are applied in real-world situations.

Metaethics

Normative Ethics

Natural Law

Applied Ethics

Justice is one of the foundational principles of biomedical ethics. Justice is understood as the fair and equitable treatment of others.

In this context, Justice refers

to fair access to healthcare, or health equity.

metaethics and where moral codes come from.

to the Hippocratic Oath: First, do no harm.

to legal consequences a person will suffer if they do not make the right moral choices.

Principlism in biomedical ethics is best described as

a central feature of the Moral Foundations Theory.

ethical pluralism.

ethics based on foundational principles that are universal.

an intuitive, emotional approach to ethics.

True or False: Principlism is attractive because of its simplicity.

True

False

Ethical pluralism in biomedical ethics is best described as

a central feature of the Moral Foundations Theory.

ethics based on foundational principles that are universal.

a rejection of the paternalistic approach to ethics.

norms that are not necessarily universal but can be diverse.

The Code of Ethics for Pharmacists, Tenet I, refers to the pharmacist-patient relationship as

paternalistic.

a covenantal relationship.

pluralistic.

a communal relationship.

Which of the following is or are the benefits of ethical practice in medical practice?

It improves the job satisfaction of healthcare professionals

It reduces healthcare professional burnout

It improves patient care and outcomes.

All of the above

True or False: the Hippocratic Oath is founded on the principle “First, do no harm.”

True

False

Informed consent is considered essential to which of the following principles?

Digital empathy

Autonomy

Confidentiality

The disinhibition effect

References

Varkey B. Principles of Clinical Ethics and Their Application to Practice.

Med Princ Pract. 2021;30(1):17-28. doi:10.1159/000509119

Mertz M, Kahrass H, Strech D. Current state of ethics literature synthesis: a systematic review of reviews. BMC Med. 2016 Oct 3;14(1):152. doi: 10.1186/s12916-016-0688-1. PMID: 27716264; PMCID: PMC5052713.

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Soofi H. Respect for Autonomy and Dementia Care in Nursing Homes: Revising Beauchamp and Childress's Account of Autonomous Decision- Making. J Bioeth Inq. 2022;19(3):467-479. doi:10.1007/s11673-022- 10195-7

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Erstad BL. Ethical Decision-Making in the Pharmacists' Patient Care Process. Am J Pharm Educ. 2022;86(3):8655. doi:10.5688/ajpe8655

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doi:10.24926/iip.v10i2.1389

Haddad AM. Reflections on the Pharmacist-Patient Covenant. Am J Pharm Educ. 2018;82(7):6806. doi:10.5688/ajpe6806

American Pharmacists Association. APhA. 1994.

https://www.pharmacist.com/Code-of-Ethics. Accessed March 10, 2023.

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Gamble N, Holler B, Thomson S, Murata S, Stahnisch FW, Russell G. Is the Writing on the Wall for Current Medical Oaths? A Brief Historical Review of Oath Taking at Medical Schools. Med Sci Educ. 2019;29(2):603-607. Published 2019 Feb 12. doi:10.1007/s40670-019-00704-6

Parsa-Parsi RW. The Revised Declaration of Geneva: A Modern-Day Physician's Pledge. JAMA. 2017;318(20):1971-1972. doi:10.1001/jama.2017.16230

American Pharmacists Association. Oath of a Pharmacist. APhA. 2022. https://www.pharmacist.com/About/Oath-of-a-Pharmacist. Accessed March 10, 2023.

Peel M. Human rights and medical ethics. J R Soc Med. 2005;98(4):171-

173. doi:10.1177/014107680509800412

Owens CT, Baergen R. Pharmacy Practice in High-Volume Community Settings: Barriers and Ethical Responsibilities. Pharmacy (Basel). 2021;9(2):74. Published 2021 Apr 3. doi:10.3390/pharmacy9020074

Kruijtbosch M, Göttgens-Jansen W, Floor-Schreudering A, van Leeuwen E, Bouvy ML. Moral dilemmas of community pharmacists: a narrative study. Int J Clin Pharm. 2018;40(1):74-83. doi:10.1007/s11096-017-0561-0

Rothstein MA. The Hippocratic bargain and health information technology. J Law Med Ethics. 2010;38(1):7-13. doi:10.1111/j.1748- 720X.2010.00460.x

U.S. Dept. of Health & Human Services. FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency. HHS. 2020. https://www.hhs.gov/guidance/document/faqs-telehealth-and-hipaa- during-covid-19-nationwide-public-health-emergency. Accessed March 10, 2023.

Nittari G, Khuman R, Baldoni S, et al. Telemedicine Practice: Review of the Current Ethical and Legal Challenges. Telemed J E Health. 2020;26(12):1427-1437. doi:10.1089/tmj.2019.0158

Cain J, Fink JL. Legal and ethical issues regarding social media and pharmacy education. Am J Pharm Educ. 2010;74(10):184. doi:10.5688/aj7410184

Terry C, Cain J. The Emerging Issue of Digital Empathy. Am J Pharm Educ.

2016;80(4):58. doi:10.5688/ajpe80458

DISCLAIMER

The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.

Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course, or course material.

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