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New edition of Creighton professor's pharmacy ethics book adds studies on health insurance, opioid abuse

. The third edition of Case Studies in Pharmacy Ethics (Oxford UP, 2017) takes on new questions arising out of the continuing evolution of health care delivery and explores the broad range of ethical issues that pharmacists encounter in practice. The text uses cases to examine such issues as health insurance, assisted suicide, and opioid abuse that routinely make national headlines. As rapidly disorienting as the health care system seemingly gets with each passing hour, there are still moments for clinicians to pause and ponder the how and why of their execution of their professional responsibilities, and to ask questions and get a firmer footing on complex cases and issues.

That’s the upshot of the latest edition of a book co-authored by Amy Haddad, PhD, the Dr. C.C. and Mabel L. Criss Endowed Chair in the Health Sciences and the immediate past Director of Creighton University’s Center for Health Policy and Ethics. The third edition of Case Studies in Pharmacy Ethics (Oxford UP, 2017) takes on new questions arising out of the continuing evolution of health care delivery and explores the broad range of ethical issues that pharmacists encounter in practice. The text uses cases to examine such issues as health insurance, assisted suicide, and opioid abuse that routinely make national headlines.

In the nine years since the second edition was published, Haddad said much has changed to give providers pause, especially in pharmacy, where drug distribution and questions of equitable distribution of drug resources within institutions or managed care organizations have regularly arisen.

“Pharmacists are the medication experts on the health care team. Pharmacists provide medication therapy management so that patients get the best benefits from their medications,” said Haddad, who co-authored the book with Robert M. Veatch, PhD, at the Kennedy Institute of Ethics at Georgetown University, and E.J. Last, PharmD, JD, a pharmacy clinician and hospital ethics consultant. “Like other health professions, pharmacists are legally and morally accountable for their actions. Pharmacists sit at a very critical place in the delivery of health care. In the context of the law, a prescriber — a physician or nurse practitioner with prescribing privileges — is a learned intermediary. So, when it comes to someone who can serve as a mediator between the business-savvy of a drug companies, the prescriber and patient, the pharmacist is the last line of ensuring the that medication-related problems are identified, prevented and resolved.”

The skyrocketing cost of new drugs has been compounded by the sudden hike in the price of some extant drugs, best documented by the spike in cost for the EpiPen, an epinephrine autoinjector used to counter anaphylaxis.

In both cases of cost hikes, Haddad said pharmacists can educate themselves and, in turn, the public, about what’s happening in the pharmaceutical industry and work to direct patients to similar drugs that can work just as effectively as the more expensive alternatives.

Haddad said the book also tries to situate pharmacists in the world of direct-to-consumer advertising, standard fare on most broadcast television these days.

“At the end of the day, the public is encouraged to ask for newer, higher priced drugs,” Haddad said. “Direct-to-consumer advertising works. However, patients, and sometimes prescribers, are not aware of what the newest drug product costs. This is where a pharmacist can intervene in the process, ask some questions and make sure that changes in the drug therapy are based on the best facts available, not just advertising.”

When the second edition of the book was published in 2008, the Affordable Care Act was not yet written, much less being debated. A decade on, the ACA has been implemented and fought over and a rival measure, the American Health Care Act, has passed the U.S. House of Representatives and is now being scrutinized in the Senate.

A set of case studies in the book explores the ACA’s workings and its potential gaps, focusing on the confluence of justice and health care.

“When you talk ethics in health care, health professionals sometimes react by stating that they do not have time for a philosophical debate,” Haddad said. “We’re not trying to be overly philosophical. Yet, the ethical issues that pharmacists face are complex and deserve some time and attention to get to the heart of the problems that exist at the individual, institutional and societal level. You have to have some self-awareness and ethical tools to apply to practice, to be able to act with any confidence. We hope the book provides such tools and case-based questions at the level of value decisions, ethical decisions and clinical decisions.”

As Creighton moves into a collaborative care model in its health science education, Haddad is also hoping to see a more interprofessional ethical decision-making. Trained as a nurse, Haddad said she’s brought that sensibility to her work across the professions, and she’s also come to realize that all health care professionals, hopefully, start from the ethical position of caring for the patient.

“We all bring different perspectives and expertise to the clinical setting, but the main thing is that everyone cares for the patient,” she said. “That’s what the book is bringing to the conversation. It’s asking that everyone — physician, nurse, pharmacist, dentist, occupational therapist and physical therapist — take that moment to stop, pause, breathe, and to think critically about questions of ethics together.”

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