Pharmacists’ Perceptions of Ethical Dilemmas Encountered in Acute Care/Institutional Practice

Purpose: With an evolving role in patient care, pharmacists face increasingly complex ethical dilemmas in clinical decision-making. Yet, pharmacy-specific guidelines and education regarding best practices in ethical decision-making are limited. This knowledge gap may increase outside factors influence on pharmacists’ responses to ethical dilemmas. Thus, there is a need to characterize influences and processes whereby hospital pharmacists currently make ethical decisions.

Methods: Descriptive study conducted through anonymous, web-based survey evaluating responses of hospital pharmacists to clinical case scenarios involving ethical concepts: autonomy, nonmaleficence, justice, and confidentiality. The survey was distributed to pharmacists throughout seven states collected demographic and education information, and presented clinical case scenarios and queries regarding factors on which the response to the scenario was based. Factors ranked on a Likert scale. Results analyzed using descriptive statistics.

Results: Sixty-two responses collected from September 2019 to February 2020; 44 included in the final analysis. Participants primarily based in Utah, working decentralized acute care in hospitals with over 500 beds. Variance existed in which factors influenced survey participant responses to each clinical scenario. Four (code of ethics, legal obligations/laws, education/personal experience, personal values) of six influencing factors analyzed had the greatest weight on ethical decision-making.

Conclusion: Variability was found across pharmacists’ clinical responses to ethical dilemmas. This variance may influence patient care. Study results reinforce that pharmacists display clinical judgment skills and that moral reasoning is guided by ethical tenants. Opportunities for further education were identified to help refine and develop these skills as the paradigm of practice and changing roles in pharmacy continue to progress.

Published in College of Pharmacy, Virtual Poster Session Spring 2020


  1. Hi Katherine,
    Great job with Jim Ruble on this work. Are you able to share the clinical case scenarios to which the respondents were asked? At least in a general manner.

    1. Thank you Dr. Munger! I am currently working with Dr. Henchey to get a PDF added to my page so that everyone can view the scenarios that were asked in the survey. If you would like, I can send you a personal copy as well.

  2. Troubled relationship with physicians and/or patients can affect patient care? This is disconcerting. Thank you.

    1. Thank you for your comment Jane! We probably didn’t delve into the effect that relationships may have on influencing ethical decision-making as much as we could have. Still, it is an exciting concept and something worth looking into.

  3. KC, very well done. I really liked the way you presented the findings, with the use of the different colors for the different influencing factors. While the graphs are “busy,” they are easy to understand. I am quite surprised that religious/spiritual beliefs had such a small influence in any scenario. I have to admit that my bias was that it would have a more significant influence. Were there any findings that surprised you?

    1. Thank you Dr. Keefe! I would agree with you; I felt religion/spiritual beliefs would have more of an influence on pharmacists’ ethical decision-making.

      Another aspect that surprised me was the low number of hours of ethics training that pharmacists’ reported having over the last two years, and the lack of experience in the field. Yet, overall, most pharmacists felt confident in their ethical decision-making. I have wondered if this stems from pharmacists in the acute care setting, working as part of a larger healthcare team? It would be interesting to delve into this further. I do appreciate that there was a consensus that pharmacists would appreciate more training in this area though!

  4. Very nice work, KC! Are you planning on submitting this for publication? What journals are you targeting?

    1. Thank you Dr. Witt! Initially, we were planning on submitting it to AJHP. However, due to the low number of responses to the survey, we are uncertain if it would be accepted at this time. Still brainstorming with Jim exactly how we would like to get the results we found out there.

  5. Interesting stuff! I’m surprised the institutional policies are so much lower than the laws and code of ethics. I wonder if those polices just aren’t written to address these dilemmas so it falls to more national standards. Or alternatively, national standards cover it, so they don’t have to.Like Dr. Keefe, I’m a little surprised religion is so low as well, but I suppose in such a legally regulated profession that might just reflect church-state separation.

    1. Thanks Dr. Henchey! This was a really fun project to work on. It definitely brings about a lot more questions that we can hopefully answer in the future.

  6. I enjoyed reading your study but it was not clear to me what “factors” were evaluated and how they were evaluated? Did respondents indicate a response to a series of questions that were driven by the ethical frameworks (e.g, autonomy, nonmaleficence, etc)? The scenario was difficult to read on the poster – it would be good to provide some details on the scenario and what type of responses it was suppose to elicit.

    1. Thank you Dr. Malone! We were able to attach a PDF of the full survey in a link below the abstract above. Feel free to look it over! Hopefully, it can help clarify some of the questions that you have.
      The influencing factors that we assessed included: personal values, institutional policies, code of ethics, religion/spiritual beliefs, education/personal experience, and legal obligations/laws. We asked each pharmacist to choose a provided response to the clinical case scenario that we presented. From there, we had them use a “slider bar” with a Likert scale from 0 (no influence) to 10 (highly influenced) to assess the level of influence each of the 6 factors had on their response to the scenario.

  7. This is a fascinating study. I will echo that the lack of ethics training is concerning, and I feel fortunate that we had a small taste of if in Dr. Ruble’s class.

  8. Kathy,
    Very interesting study and results. What would you do differently if you could do this study over? What would be the next study you think should be done to carry this work to the next level? If you were someone in Linda Tyler’s position, what would recommend or try to implement for your pharmacists?

    1. Thank you Dr. Blumenthal! Ideally, we would have found a way to get more participation in the survey so that we could make better comparisons between the different demographic groups (years in practice, # of hours of ethical training, etc.). As for the next stage of this study, I think it would be fascinating to find out how much training and education regarding ethical dilemmas there is currently available to pharmacists. This would give us an idea about what kind of training is out there and where/if a need exists in certain areas.

      In healthcare institutions where pharmacists are taking on more sophisticated roles as part of the healthcare team, I believe it would be worthwhile to offer CE, guidance documents, or additional training focusing on resources to help pharmacists navigate the ethical dilemmas they are exposed to in practice.

      I had a lot of fun with this project and look forward to continuing research in this area in my future practice.

  9. Hi K.C.
    Great poster and content. In nursing school we would talk about different scenarios and what played into our own decision making regarding ethical dilemmas. The fact that we acknowledge that there are many factors and who we are and what our experiences are influence those rankings help start that dialogue. As you conclude – More shared dialogue and education on this important issue helps all. Sure exciited you’ll be finishing soon! Congratulations

    1. Judy, thank you so much! Yes, I agree it is so important to talk about these things! I can’t believe that graduation is right around the corner… Thank you for everything throughout these last four years!

  10. What a great topic of study! Were any of the pharmacists you surveyed from a VA hospital practice? I enjoyed the presented scenario and agree that it presents a great venue for discussion. Ethical decision-making needs more attention, especially for curricula in professional programs. Thank you for sharing these data! Excellent work!

    1. Thank you Dr. Orlando, I had a great time working on this project with Jim! We distributed the survey in a few different ways, and it may have reached pharmacists at the VA. Unfortunately, due to the use of the anonymous weblink, we aren’t able to tell if any pharmacists from a VA hospital specifically were included. Next time around, we will be sure to target more VA institutions!

  11. Really proud of you. This is a nice outcome from your work. I also mentioned this on Chelsea’s poster,… wish we could have added a scenario about pandemic response. Of course, 2.5 years ago when we were planning these studies, pandemic was a mythical creature that only appears once every 100 years.

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