Deontological problems facing pharmacists today
Gonzalo Herranz. department of Bioethics, University of Navarra.
lecture series-colloquium on ethics and pharmaceutical deontology.
high school of Pharmacists of Navarra.
Pamplona, June 6, 1991
I. The need for a Code of Ethics
II. Physician/pharmacist relations
III. On the moral independence of the pharmacist
IV. Relationships between pharmacists
-Appreciation.
The organizers of these Conferences -colloquium - have suggested to me some topics that seem problematic for pharmacists today. They form a rather disparate group. As I have understood them, I am expected to allude, in the first place, to the debated problem of the need for a professional Code of Ethics. And then to deal with other things:
- Physician/pharmacist relations.
- On the moral independence of the pharmacist, in the hospital and in the office.
- On relationships between pharmacists in a time of unemployment.
And if there is time left, of the new recipe. And there will be no more time. I think that in the discussion following my intervention, we will all be free to ask and answer.
I. The need for a Code of Ethics
In the preamble of the FDC, accredited specialization refers to the recommendation of the European Pharmaceutical Grouping that each member association should enact a FDC, containing the professional duties that define pharmaceutical ethics and that are not included in the respective legislations.
For me, this has two surprises. One is that it has been possible to reach 1991 without a FDC. The other is the strong prevalence of legislation over deontology in the pharmaceutical profession.
It is surprising that in an era fraught with ethical tensions - the tension between therapeutic austerity and pharmacological hedonism, the tension between pharmacy-business and pharmacy-school and health agency, the tension between information and advertising, the tension between the pharmacist's freedoms and the rights of customers, the problems linked to the progressive regulation management assistant, to the functionalization of professionals, to conflicts of interest, etc. - it is surprising that in an era fraught with ethical tensions - the tension between therapeutic austerity and pharmacological hedonism, the tension between pharmacy-business and pharmacy-school and health agency, the tension between information and , the tension between the pharmacist's freedoms and customers' rights, the problems linked to the progressive regulation , to the functionalization of professionals, to conflicts of interest, etc. It is surprising that in the era of ethical tensions that we have been living through since the 1960s, there has been no CDF project among us until a few months ago.
In such a status , professionals are logically guided by the traditions received from the past. Thanks to them, it is possible to solve many problems that are simply new presentations of already known issues. Above all, one tends to rely on one's own moral intuitions, on the desire to maintain the conduct that one considers righteous, to follow what seems to one professionally more worthy or simply acceptable. In such a status we move towards the inevitable indeterminacy that some call deontological pluralism, which refers not only to different ways of evaluating moral problems, but also, and above all, to the different levels of rectitude and moral demands that each person sets for himself or herself. When there is no code, but there are problems, it does not take long to reach the conclusion that things are not clear; that everyone can follow the dictates of his or her own conscience; that, in deontology, everything is relative because no one can impose his or her moral point of view on another.
This is a catastrophic mistake. Because the professions are either guided by the deontological rules that they give themselves, or they are governed by legislation. It is impossible for the professions to function without rules. It is a typical, essential feature of the professions to have a Code of Ethics, which guarantees their fundamental freedom to do something for their clients that is above the ethical minimum required by law, since it is a right of the people to receive from professionals a qualified service when they place in their hands things of such incalculable value as their health, their legal assets, their moral values.
It is not possible to imagine an anarchic, anomic professional activity, without principles or ethical norms, governed only by laws. Because the professional, to be manager, must be free. But he needs that freedom to use it, not to his advantage, but to the best service of his clients. He needs both autonomy and self-regulation. Autonomy here means the guarantee that the professional can freely give his professional opinion on what constitutes the most appropriate service for his client, without this judgment being influenced by political power, the desire to make money, or social prejudices. Along with the right to professional autonomy, the profession, organized corporately, is assigned the permanent responsibility to establish binding ethical rules that regulate the conduct of its members, to guarantee the quality and the homogeneous skill of its services, to demand that the right interests of the clients take precedence over the particular interests of the professional.
Only with a Code of Ethics can the professions establish a sensitive and active system for honestly and objectively evaluating problems, conflicts, errors and negligence that arise or occur in professional practice. Violations of professional ethics must be evaluated and eventually punished with serenity, fairness and promptness. It is a fact that this assessment can only be carried out by professionals, who are the only ones qualified to perceive what is justifiable and guilty in the conduct of a colleague. At a time when the unification of jurisdictions is an unstoppable trend, judges in advanced countries (including those of the Supreme Court of the EC) recognize that the only non-ordinary jurisdiction that must remain independent is the deontological one.
I conclude this first point of mine by saying that a Code of Professional Ethics is necessary for several very important things: to guarantee professional independence from political power, to require professionals to behave much more finely than the minimum ethical standard of the law can impose, to judge professionals who disappoint the expectations of the people, who have the right to be treated with dignity and skill.
I move on to my second point.
II. Physician/pharmacist relations
There is not much that the CDF prescribes about these relationships. Its article 6 says that "the Pharmacist shall establish an open partnership with all professionals acting in the service of mankind". And further on, article 47 adds that "Whenever he/she deems it appropriate, the Pharmacist shall advise patients to consult a physician". Logically, it prohibits the association of physicians and pharmacists for profit: the article 51 states that "The association for profit of pharmacists with physicians or other health professionals in the field of their professional activity shall be avoided in any case...".
On the other hand, in the Code of Ethics and Medical Deontology there is a very brief chapter dealing with the physician's relations with members of the other health professions. Not much has survived in the final text of the primitive draft . The latter's approach, which was very open to cooperation and mutual appreciation of the respective competencies, has been reduced to a general duty of good relations and a pact not to invade the territory of others. There is practically no mention of respecting the technical and ethical autonomy of all those involved in patient care.
Deontological respect in this field includes not only the set of gestures imposed by good Education, but something more profound: the recognition that those who work in the service of health are true professionals, who enjoy autonomy and skill, who have the right to be treated as responsible and knowledgeable persons in the corresponding subject, and also as morally adult persons, whose convictions and dignity must be taken into account as much as those of the physician himself/herself.
The responsibilities of each profession must be known to each other as precisely as possible, in order to avoid conflicting situations.
Physicians should refrain from recommending that their patients go to a particular pharmacy office in preference to others. He will never make directly or indirectly pejorative comments about the quality and price of the services provided by a particular pharmacist. On the contrary, he will be strictly impartial towards all pharmacists working in his environment. In the deontological tradition of Western European countries, there are very precise rules to avoid any subject collusion between physicians and pharmacists, and to guarantee their moral independence and the economic transparency of their relations.
If the physician suspects that a product (specific or magistral formula) dispensed by a pharmacist is not in good condition or does not correspond to the one he/she has prescribed, he/she will discuss the matter directly with the pharmacist manager, never through the patient or in his/her presence.
And just as the physician must respect the pharmacist's interventions, the pharmacist will refrain from criticizing the content of prescriptions to his customers or undermining his reputation with patients. The pharmacist may advise his customers informally on the treatment of obviously minor ailments and dispense medicines that are advertised, i.e. that do not require a prescription. But he can never replace the doctor in his diagnostic and therapeutic function, nor, except in emergencies, perform minor interventions or cures that could have the appearance of unfair skill .
But, above all, it is up to pharmacists to act as drug experts, especially in the field of prevention of drug-drug interactions, and in the Education and information of patients on subject of drugs. Pharmacists have a formidable professional task in this area, both socially and in terms of health, high performing. They are, therefore, ethically and legally authorized to substitute, not only in case of need due to lack of stock, but also to avoid interactions or prevent unwanted effects, with other identical or equivalent drugs prescribed by the physician. I think that in all cases of generic substitution and, in particular, in those of therapeutic substitution, they should always act with knowledge and prudence. And part of this prudence and this knowledge consists in contacting the physician at contact to inform him/her of the opportune extremes and to act with him/her at agreement .
It happens that, on occasion, there are in fact strong and significant discrepancies between the opinion of the physician and that of the pharmacist. This disagreement may concern both the moral content and the technical aspect of the prescription. The pharmacist should communicate to the physician the reasons for the disagreement and the physician should listen to them and modify or maintain the order after calmly considering the data of the problem raised. The physician may insist that he/she has the ultimate responsibility to the patient and even demand that his/her prescriptions be complied with, making position himself/herself responsible for all the consequences. However, no one can ever force another to act against his own conscience or to do something that seems to him to be contrary to reason. Neither in medicine nor in any other field of human activity can anyone's conscience be violated. Nor can anyone justify their actions by claiming that in their work they are simply carrying out orders from others: such an attitude is professionally indefensible, both from the ethical and legal point of view.
Physician and pharmacist are two morally mature human beings who render their best services to the patient to the extent that they base their decisions on solid scientific and deontological foundations. It is foolish to think that the best collaborators are the most obsequious, those who reduce their morality staff to an ethic of submission. Moral responsibility can only be built on the basis of freedom and professional skill .
III. On the moral independence of the pharmacist
Having noted the foregoing, I think it is worthwhile to discuss in some detail this topic of the ethical independence of the pharmacist. I will focus my commentary on a threat, fortunately very fleeting but significant, that was recently insinuated among us against this independence.
There was a time when not one, but several Ministers declared that the Government would not tolerate pharmacists' conscientious objection to the sale and dispensing of condoms, since they were studying the inclusion of prophylactics in the list of pharmaceutical products that must be dispensed. This is a tremendously serious decision: if there is any moral progress we can be proud of today, it is the respect for personal freedoms that has been established in our days, the recognized right to dissent from the dominant social convictions, the intangibility of consciences, the rejection of coercion, the condemnation of moral violence.
What serious reasons did the Government have for fail such a fundamental right as the right to conscientious objection?
The Ministers' advertisement took place in the course of the well-known campaign to curb the spread of HIV infection. It is important not to forget the conditions under which this campaign emerged. The growing threat of AIDS and the urgent need to do something to contain it led WHO, and the Ministries of Health with it, to launch a strong public education campaign by means of leaflets mailed to all citizens, and television, radio and press advertising messages on the circumstances of contagion and prevention of the disease. The campaign included, to varying degrees depending on the circumstances, facilitating the use of sterile syringes to drug addicts and disseminating the notion of safe sex through the use of condoms or non-penetrative sexual practices to the general population, especially adolescents. For one reason or another, it affected pharmacists.
I did not hide my disagreement with the purposes and manners of the campaign. In the course of an interview published in some newspapers, I went so far as to accuse the promoters of the campaign of irresponsibility. I did so for a fundamental reason: the serious, deliberate disfigurement of a message which, although absolutely far removed from any religious confessionalism and stripped of any moralizing intention, dictated criteria based on the common, classical, proven rules of preventive medicine. The message of good biological conduct proposed by the highest authority in the subject, the Centers for Disease Control, the famous CDC, in Atlanta, Georgia, in the United States, must have been catalogued in our Ministries as a product of the puritanism of the South and was eliminated with the stroke of a pen. This is the story.
The CDC, after mature reflection and lengthy expert discussions, published a series of articles on AIDS prevention in its official organ, the Morbidity and Mortality Weekly Report, throughout 1988. One of them, graduate "Condoms in the prevention of sexually transmitted diseases", appeared in February 1988. In its Introduction, which I have translated in full, it stated the following: "Prevention is the most effective strategy for slowing the spread of sexually transmitted diseases (STDs). Behavior that eliminates or reduces the risk of one STD will probably reduce the risk of other STDs. Preventing one case of STD can result in result the avoidance of many subsequent cases. Continence and sexual intercourse with a mutually faithful and uninfected partner are the only fully effective preventive strategies. The correct use of condoms with every sexual act can reduce, but not eliminate, the risk of STDs. Individuals susceptible to infection or who know they are infected with human immunodeficiency virus (HIV) should be aware that condom use cannot completely eliminate the risk of transmission to themselves or others." (Centers for Disease Control. Condoms for prevention of sexually transmitted diseases. Morbidity and Mortality Weekly Report 1987;37:133-7).
The Weekly Epidemiological bulletin , published by the General Subdirectorate of Health and Epidemiological Information of our Ministry of Health and Consumer Affairs, reproduced in its issue No. 1801, from January 31 to February 13, 1988 (printed on July 11 of the same year) a summary of the above-mentioned article of the MMWR. I still doubt if it is really a summary, or if it is not rather a censored article . Because one cannot help but wonder whether one can call summary the translation of the full text, from which the information specific to the United States (basically data and administrative regulations on quality control of condom batches, American or foreign manufactured) has been removed, which is reasonable, and, on the other hand, the following lines: a) in the Introduction cited above: "Continence and sexual intercourse with a mutually faithful and uninfected partner are the only totally effective preventive strategies."and b) in the final paragraph: "Recommendations for the prevention of STDs, including HIV infection, should emphasize that the risk of infection is effectively eliminated by continence or sexual intercourse with an uninfected and mutually faithful partner.
When comparing the American original and the "summary" of the Spanish Ministry, one cannot avoid the suspicion that between one and the other there has not been an honest operation of summarizing, of abbreviating in concise terms the essence of the original writing, but that a substantial part of the document has been crossed out with the red pencil of censorship. The content of these sentences must have seemed to the censor to be unbearably moralizing and unbecoming of a tolerant and permissive age. And, in order not to run the risk of appearing gauche, he preferred to be perverse. He has branded what must have seemed to him a sample of religious fanaticism, without realizing that he was doing so because of his own ideological fanaticism. And he was wrong: because sexual abstinence and sexual intercourse with an uninfected and mutually faithful partner are, in addition to human behaviors full of moral values, biological behaviors full of common sense.
This is how Dr. Theresa L. Crenshaw, of San Diego, California, President of the American Sex Educators, Counselors and Therapists association , expressed herself in her testimony before the congress of the United States, in February 1987. She said, "For health reasons, casual and promiscuous sex must be abandoned. And while recognizing that condoms in combination with spermicides can help in the fight against AIDS, we must insist on the need to emphasize the importance of behavior change. It is irresponsible for many authorities to resign themselves to the hopelessness of the AIDS threat and to limit themselves to softly slowing down its spread by recommending condoms. People need to be told clearly that they should avoid all sexual activity with anyone other than a 'committed partner'." The message from Theresa Crenshaw and the association she chairs is that "people can change their sexual behavior, but they won't if we don't trust them, if we don't talk to them clearly, if we just offer them sex light" (Goldsmith MF. Sex in the age of AIDS calls for common sense. JAMA 1987;257:2261-4).
This has to do with the important social function of the pharmacist as a health educator. If he is to exercise this function responsibly, he must remember that the rules dictated by experts or politicians depend directly on the idea that they, each one of them, have of man. Underlying every political decision and, for that matter, every health policy decision, is an anthropology, that of the politician or the health professional, and also, inevitably, a moral one. This is usually concealed. And this is usually concealed with a slogan: in a pluralistic society, it is said, no one can impose his or her convictions on anyone. Indeed, the best thing is to have no convictions at all. But that is inhuman, it does not stand up. The condom campaign has a mentality behind it, just as those of us who think that the campaign was a tremendous mistake have a mentality. The mentality that informed the campaign corresponds to a zoological notion of man, to a pessimistic notion of social life. In reality, such a campaign was designed primarily for teenage boys and girls, predominantly black and Hispanic, from the old part of the big American cities, made up in their vast majority of homeless and unschooled kids, brutalized by the struggle to survive, mistreated by a surrounding, affluent and indifferent society. The message that has been addressed to them has come to be more or less this: You are hopeless: you are incorrigible! -You can never redeem yourselves! Your only compensation in life is sex and drugs: take a few syringes and a handful of condoms! This is, ultimately, the Philosophy of the campaign of our Ministries: the same pessimistic vision of youth, hopelessly hooked to promiscuity, to the trivialization of love, incapable of ideals, closed to fidelity.
But we are not only dealing with a falsification or cancellation of moral values. The campaign spreads an epidemiological exaggeration. People need to be told that AIDS prevention must be taken much more seriously than the youthful condom campaign implies. In the case of AIDS, prevention is not simply better than cure: it is the only cure.
What do we really know about condom efficacy? One of the most comprehensive and critical reports is prepared by Prof. W. E. Schreiner of the University of Zurich and Dr. K. April of the Swiss AIDS Information Office. In a work published a few months ago (Zur Frage der Schutzwirkung des Kondoms gegen HIV-Infektionen, Schweizerisches medizinisches Wochenschrift 1990;120:972-978) they point out that: "Condoms have been recommended in several countries as the most important mode of protection against HIV infection, but there is no serious evidence that they are effective and to what extent against sexually transmitted diseases (STDs). Before the HIV epidemic, condoms were used to try to prevent pregnancy and to reduce the risk of contracting STDs. To prevent a deadly infection such as AIDS, safe modes of protection are mandatory. The most recent programs of study on AIDS prevention demonstrates that the assumption that condoms offer reliable protection against HIV is a dangerous illusion. Carefully planned programs of study has shown that condom employment reduces the risk, but a residual risk remains, ranging from 13% to 27% and more."
The problem is very serious. Not only because the condom presents that wide window to HIV infection. It is that the assessment of its efficacy is practically forbidden to us. We will never be able to design prospective experiments to measure its protective effect. No Ethics committee will ever be able to approve a clinical experiment comparing two groups, one using condoms and the other not using condoms, in which initially uninfected subjects had, for a given period of time, standard sexual relations with other infected subjects, in order to evaluate the net rate of protection conferred by the condom.
In view of these data, what can we say about the government's pretension of not accepting the conscientious objection of doctors and pharmacists who did not collaborate in its campaign and who did not prescribe or dispense condoms? I think it was a threat that was not serious. It is something that can be said to soften the moral resistance of some, or to gratify the exhibitionism of power of a few. But it seems to me to be a tremendous mistake, both in the field of civil coexistence and in that of scientific dialogue.
Such a measure would constitute, on the one hand, a sample of intolerance, unbecoming of a modern state, respectful of individual liberties and which, moreover, enshrines in our Constitution the intangibility of consciences. It would be, moreover, the violent imposition of a particular moral opinion, a tragala of the Administration, which has anticipated to label as intolerant those who do not collaborate. No one, including physicians or pharmacists, can be forced, in a state governed by the rule of law, to disconnect his or her own moral convictions from his or her technical actions, to carry a double standard, to act against conscience.
Such a measure would constitute, on the other hand, an intrusion of political power in the field of scientific discussion. If a doctor or pharmacist judges, based on reliable scientific data , that condoms do not provide acceptable protection against HIV, they are not obliged to recommend or dispense them. Their decision is rational and they should make this clear to their patients or clients. They should calmly inform them that, although they protect between 75 and 85 percent of cases, the risk rate is between 25 and 15 percent, i.e., they fail in one out of every four to six sexual contacts. As long as AIDS remains a deadly disease, that is an overwhelming risk. "That, by using a condom, you can have truly safe sex with an HIV-positive partner is a dangerous illusion."
This is the committee that physicians and pharmacists should transmit. Modern ethics has placed at the forefront of the relationship between professionals and clients the need for the decisions they make together to be free and informed. Freedom can only be exercised ethically when the necessary information is available, when the data have been understood. This is the only way to decide in conscience and freedom. We are no longer in the era of harsh paternalism, when the patient was limited to passively following the decisions that the physician or pharmacist made for him. The patient can no longer ignore. Nor can he be deceived. The doctor's office and the pharmacy counter are places of high ethical tension, where each person must be treated as an ethically mature human being. In truly ethical relationships, there may be disagreements on occasion, but there is no room for deception or abuse in either direction. Disagreement should be polite, respectful of persons, limited to the point of disagreement, and justified by serious reasons of science or conscience.
This will not be the last attack on the moral independence of the pharmacist. I am sure that in the future the pharmacist will have to continually defend his freedom and responsibility. It is a matter of conscience and science.
IV. Relationships between pharmacists
A topic of great ethical content is that of cooperative relationships between pharmacists. The Pharmaceutical Code of Ethics is not very specific on this matter. The article 10 states that "Pharmacists shall give test of solidarity, supporting each other in the performance of their professional duties." Already, more specifically, article 11 imposes on the pharmacist the ethical obligation to call on a colleague to share with him the burden of work, when it exceeds his own capacity. The article reads as follows: "If a single Pharmacist is insufficient to provide the service required by society in his professional modality , he must promote the incorporation of another or other Pharmacists to ensure the perfect fulfillment of the act and of the pharmaceutical service". Already in the specific context of hierarchical relationships, the article 17 recommends to whoever directs teams dedicated to the research, the teaching, or the management to contribute to the best coexistence, efficiency and equanimity to preside over the work and the relationships between the members of the groups; and articles 58 and 59 do so of the hospital pharmacy groups: The hierarchical organization must be based on the moral and scientific authority of those in charge and on the freedom manager of all, on mutual respect and on the recognition of the right to abstain for reasons of conscience. And, always, in his actions as a pharmacist, he must be guided by essential criteria of independence and responsibility staff, says article 14.
It should be borne in mind that the relationships between pharmacists are qualified relationships, not simple labor relationships between patron saint and worker, between employer and employee. The application of common labor legislation can give rise to unethical contracts, lacking in professional respect. In the labor regulation in force today, some modalities of special contracts are authorized to alleviate the drama of unemployment, which consecrate very asymmetrical labor relations, poor in rights, fleeting in time, without guarantees of continuity. They may be justified either as emergency social remedies or as solutions that combine the professional training with the youth employment .
Pharmacists who associate as colleagues or who sign a service lease contract are always colleagues among themselves, members of the professional organization, endowed with the same rights, invested with the same dignity. There is no room for abuse or exploitation of some colleagues by others. The Regulations of the Official Colleges of Pharmacists include, among the competences of each high school (art. 5, 18), "To dictate the appropriate rules for the appointment of pharmacists regents, assistants and substitutes, and to intervene, in any case, in the payment of the fees that they should receive, ensuring that the relationship between the pharmacists who own pharmacy offices and the aforementioned assistants and substitutes constitute a professional partnership , without labor character".
The General Statutes of the WTO impose the obligation to submit for approval by the board Directive of the high school any contract for the provision of services signed by any physician. Failure to do so is classified as a less serious misconduct.
I believe that this tradition of respect can suffer a serious deterioration in a status of medical unemployment, where it is easy to subject young colleagues seeking their first work to abusive and even humiliating conditions. From the Central Commission of Deontology of the CG de Colegios de Médicos we have ordered the systematic review of these contracts, which often contain clauses that, although acceptable to the labor courts, disregard professional dignity, limit the freedom of the contracted physicians, impose economic incentives that put their professional integrity at serious risk, and create unbearably onerous conditions in the event that the contract is terminated before the fixed deadline .
As established in the current Code of Ethics and Medical Deontology, in its article 35.4, the Associations cannot allow the constitution of groups in which there could be exploitation of some of its members by others. The relationship between pharmacists must always be a collegial bond, a professional partnership , and cannot be reduced to a pure labor transaction. This has much more to do with human aspects than with remuneration.
I do not know whether to extend this talk for a few moments to deal with the ethical aspects of the new prescription model , which came into force on May 1. Obviously, and first of all, it is an instrument of bureaucratic control. Its data will go to feed the report of large computers and it will be very easy to obtain data then of the prescribing trends of physicians, of the preferences of customers, of the consumption of the different brands and pharmaceutical forms, etc. All these data can be used for statistical, control or programming purposes, in very different contexts. The important thing is that these uses are ethical and legitimate.
Secondly, the new model can act as a deterrent to pharmaceutical consumption. Common prescriptions, and even those for long-term treatments, have a short validity period deadline . Their very structure is sufficiently complex for the proper completion of all the required data to discourage the physician from issuing prescriptions that are not strictly necessary. As a result, the volume of compliant prescriptions can be reduced.
Undoubtedly, the new prescription model could, theoretically, play an important role in patients' medication Education . However, the box reserved in the leaflet for these instructions occupies less than one eighth of the useful area : it is so small that it does not seem to be able to receive much content, apart from the dosage instructions. Nor can much be expected from the new model in terms of good physician-pharmacist communication, if everything that is to be negotiated is to be written in the box entitled Warnings to the pharmacist in the body of the prescription. It should be added that it is a positive fact that the diagnosis is protected by confidentiality, since it only appears on the patient instruction leaflet, which remains in the patient's possession.
Overall, not much can be expected from this new model, other than its further refinement and simplification.
The complaints that have been raised against him by the pharmaceutical profession refer to the undesirable consequences in terms of loss of time and delays in the payment of prescriptions dispensed that can result from the carelessness of physicians in filling out prescriptions correctly. From a deontological point of view, the physician is obliged to fill out the prescriptions as required. He is obliged to do so by contractual rules with the health authority, but above all by loyalty to his patient, whom he can never intentionally harm or treat in a negligent manner. Since the healthcare system is society's main instrument for health care and promotion, physicians must ensure that it meets the requirements of quality, sufficiency and maintenance of ethical principles requirements . And I think that part of this vigilance is to carefully comply with the established standards. They are also obliged to denounce deficiencies in the healthcare system insofar as they may affect the proper care of the sick.
Pharmacists are entrusted by the M. O. of February 1, 1990 with the task of correcting certain omissions or deficiencies in medical prescriptions. M. of February 1, 1990 the task of correcting some omissions or deficiencies in the medical prescription. This can give rise to tensions and problems. Ideally, it would be the beneficiary of the prescription who would demand in actu from the physician the perfect fulfillment of his duty, but, no matter how much the cultural level of any society grows, the sick, precisely because of their vulnerability, will never be able to fully assume this responsibility position .
It seems to me that neither bellicose confrontation with each of the doctor's oversights, nor the pharmacist systematically making up for the deficiencies and writing them on the back are a solution. In the doctor-pharmacist relationship, there must be room for friendly warnings. Occasionally, when appropriate, the patient should be entrusted with the role of demanding more correct conduct from the physician. Patients' rights, like all rights, tend to erode if they are not asserted. The patient has the right to be provided with a valid and legally compliant prescription by his or her physician.
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I want to end by again thanking you for the invitation to be here this afternoon. Professional ethics, it is apparent from many of the things I talked about this afternoon, may seem very weak in comparison to the law. It cannot be enforced by force. It can only be enforced by the moral quality of professionals who are able to discover the formidable difference between living the profession as a vocation and living it as a business. Thank you very much.