Forecast 2016: Ethical Dilemmas in Health Systems Projected to Grow

Health-system pharmacists will inevitably face growing ethical challenges as a result of their evolving role in patient care. The Pharmacy Forecast 2016-2020, published by the American Society of Health-System Pharmacists (ASHP) Foundation, analyzes pharmacy trends and provides strategies for health systems to grow and keep pace with the evolving scope of their practice.

The forecast is written annually by a panel of pharmacists believed to have (1) expertise in health-system pharmacy practice, (2) knowledge of trends and new developments in this area, and '(3) demonstrated ability to think analytically about the future of pharmacy practice in hospitals and health systems. This year, there were 159 such forecast panelists (FPs).

The majority of the domains considered in the report have been components of the forecast in years past, including health care delivery and financing changes, 'enhanced health-related data and'technology advancements, and shifting 'pharmaceutical marketplace dynamics.' Newly recognized as a 'factor in the changing' landscape of health' systems pharmacy is 'ethics.

The growing influence of ethics in health care stems “partly from the consolidation of payers and provider organizations, the growing weight of the business imperative in health care, tension between population health and individual health care, and the rapacious pricing of some medicines,” wrote advisory board committee member William Zellmer, BSPharm, MPH, in the forecast.

The particular ethical dilemmas embedded in health-system pharmacists’ daily practice include competing interests, limited resources (including drug shortages), and an evolving care delivery system, in which their role has shifted from dispensing medications to actively participating in direct patient care. The latter has created room for not only new professional dynamics, but also competing ethical viewpoints.

According to the survey results included in the forecast, 78% of'FPs said it is either “very likely” or “somewhat likely” that the number of ethical dilemmas experienced by health care professionals in health systems, and referred to ethics committees for guidance, will increase by at least 25% by 2020 (Figure 1).

James Hoffman, PharmD, MS, FASHP, an advisory board member for this forecast, exclusively told Pharmacy Times that pharmacists will play a key role in managing ethical dilemmas going forward, and that including a pharmacist’s voice on ethics committees is imperative.

“The pharmacist expertise is really unique within a health system and within these ethical dilemmas, and as more and more dilemmas come up that involve medications, then a pharmacist can be a big part of those efforts,” he explained.

One of the hot-button ethics issues in pharmacy, currently, is the trend of skyrocketing prescription costs and the lack of transparency in drug pricing decisions; and, although the US Senate launched a bipartisan investigation into prescription drug pricing, the trend is unlikely to subside in the near term.

Extremely high prices and lagging reimbursement may preclude health systems from providing needed medications to all patients. The survey found that almost 80% of FPs say that nearly all health systems will require clinicians to follow specific treatment pathways when caring for patients who are using certain high-cost therapies, such as PSCK9 inhibitors or specialty hepatitis C drugs.

Although ideally, the same metric of value and decision-making principles will be applied, when considering population health and the needs of individual patients, in the years ahead, pharmacists will likely be faced with ethical dilemmas, when reconciling population-based advice and protocols with the needs of individual patients.

Even with the inclusion of pharmacists on ethics committees appearing imminent, just a small number of FPs (9%) answered that it is “very likely” that at least 25% of health systems will consider “the ethical facets of the policies and practices of manufacturers and suppliers” in purchasing decisions.

“Patient welfare is at risk when the ethical perspective in health care is smothered by business and financial perspectives,” wrote Dr. Zellmer, “Patient well-being often hinges on the ability of health professionals to heed the ethical precepts of their calling.”

In light of the ethical forecast, the ASHP Foundation has offered the following strategic recommendations for health-system practice leaders:

1. Designate a small team of pharmacists to (a) take the lead in studying emerging ethical issues, (b) raise the profile of these issues among pharmacy staff members, and (c) represent the pharmacist perspective in systemwide deliberations and policy development on ethical issues.

2. Advocate for development of a proactively ethically sound health-system policy for rationing essential medicines that are in short supply.

3. Foster discussion of any pricing of medicines that is out of line with patient benefits. Trust that sunshine and shaming can lead to change.

4. Discuss with physicians, nurses, and other health professionals potential compromises of ethical principles and professional autonomy in the workplace.

5. Encourage pharmacy organizations to give more attention to issues related to ethics and professional autonomy, including joint consideration of these topics with other health professional associations.

Proper management of ethical considerations is of paramount importance to pharmacists in particular. They are currently vying to gain support for an expanded role in patient care in the form of provider status, and support will likely be more easily garnered if pharmacists are perceived as being on the side of the patient, rather than on the side of business interests in health care.