Approaching Ethical Dilemmas in Oncology Pharmacy

Pharmacy Times interviewed Karen Fancher, PharmD, BCOP, oncology pharmacy specialist, Duquesne University School of Pharmacy, on her presentation at the Hematology/Oncology Pharmacy Association (HOPA) Annual Conference 2024 in Tampa, Florida titled “Ethical Dilemmas in Oncology Pharmacy: When Science and Morals Collide.” Fancher discusses some examples of ethical dilemmas oncology pharmacists may experience in their work with patients and some guiding principles for approaching and addressing those challenges.

Pharmacy Times:What are some examples of ethical dilemmas oncology pharmacists may face?

Karen Fancher, PharmD, BCOP: From my standpoint, I think there's numerous ethical issues that pharmacists come across that we don't realize are ethical issues. On a day-to-day basis, I think pharmacists, especially oncology pharmacists, really struggle with the balance between what's called beneficence, like doing good for the greatest number of people and individuals, but also non-maleficence, or not doing harm. I think the nature of oncology is such that our drugs cause harm in order to do good. I think that personally, I struggle with that on a day-to-day basis: Am I harming my patient with the goal of making them better? So, with all the side effects that we deal with, and what is my end goal? I think those 2 concepts are almost like a routine part of my day-to-day job. But I don't know if pharmacists even realize we have those internal struggles as we work with our patients. From a patient standpoint, I think those 2 ethical dilemmas happen quite a bit.

I think very recently, we have broader issues like with drug shortages, and how do we allot drugs in a critical situation, which have to do more with justice and doing good for the greatest number of people. So I think there's some constant issues, but then I think we also have some that come and go throughout our course of treating patients.

Pharmacy Times: The impact of drug shortages on practices can lead to oncology pharmacists needing to make some ethically challenging decisions. What are some guiding principles for oncology pharmacists when facing these dilemmas?

Fancher: For a pharmacist facing an issue with drug shortages, I think there's a couple things to keep in mind. One would be we are never practicing in a vacuum—what pharmacists deal with to obtain those drugs or to dispense those drugs should also be considered in the context of physicians, advanced practitioners, religious considerations, ethical considerations about patients’ compliance and ability to pay. So, this should be a multifaceted team that is making these decisions on how to proceed in the sense of the drug shortage. So, while I absolutely advocate for the role of the pharmacist, and I think we should be a key stakeholder, I personally believe that it's not our decision alone, and that this has to be a multidisciplinary decision.

I think the pharmacist needs to be aware of how can we minimize the use of drugs when there is a shortage, so can we minimize waste? Can we schedule all the patients that are getting that particular drug on the same day? Just what are some things we can do to make the shortage a little less serious. If we need to restrict it even further, I absolutely feel that pharmacists should be involved in the decision making process of how to allocate drugs. I think that we should be involved actually in all levels of the planning. But I think I want to stress that we certainly need a seat at the table, but we shouldn't be the ones making those decisions on our own. This is something that affects everybody in oncology pharmacy and oncology in general.

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Pharmacy Times: For those who follow a faith-based practice, how might you recommend they navigate the intersections of faith-based morals and medical ethics?

Fancher: I think I think faith plays a big part in a lot of decisions that we make, and that is absolutely appropriate. I think that maybe what we need to step back and recall is that, in my opinion, at least, with most faith-based practices, we are trying to do good for the most amount of people. That's a guiding principle of most faiths or most religions in this country. So, is there a conflict between your faith and medical ethics? There may be but I think there's a lot more common ground than what people realize. Again, I would stress that I think we need to step back and think about [whether] my principles and faith apply in medical ethics? And how much do they overlap, and how much common ground can I find? I also believe very strongly that if I object to something as a faith-based pharmacist, I still have an obligation to that patient, [and] I still have an obligation to get them to the treatment that they're seeking, or they're asking for, even if I personally can't participate in that. I think that I have a responsibility to patients on a broader scale, even if I can't participate because of my faith-based decisions.

Pharmacy Times: This issue of navigating ethical dilemmas in oncology pharmacy seems particularly pertinent today. Are some of these challenges influencing oncology pharmacists move out of patient care, in your experience?

Fancher: I think there's lots of things at play, but you cannot deny that it is very challenging to navigate complex medical issues like drug shortages, but also individual patient ethical dilemmas. It would be foolish to pretend that that doesn't wear down on anybody. I think there's an opinion that shifting from a non-clinical role will be less ethically challenging, but I don't know if that's true. I don't practice in an industry or non-clinical setting, but my impression would be that you're still making decisions or contributing to decisions that affect a large number of people that affects drug access that are going to affect outcomes. So maybe on an industry side of things, you're affecting more people instead of an individual patient, but I think that an unmet medical ethical dilemma is everywhere.