The good, the bad, and the gray areas: Where are your ethics?

Kim Ankenbruck has a knack for expressing what many of her fellow pharmacists are thinking, as readers of her previous columns, “Who will stand up for pharmacy?” (February 2014) and “A dose of pharmacy truth: Report from the front lines” (May 2014) will attest. Here, she tackles the question of how to practice integrity in an environment designed to punish the attempt. And she has some questions for you. Post your answers at www.drugtopics.com, or send them to drugtopics@advanstar.com.

Ethical standards have always held an important place in pharmacy practice. From medieval herbalists to modern pharmacy practitioners, the local medicine man, apothecary, druggist, or pharmacist has always been a valued and trusted member of society.

These days, it seems as if our halos have started to slip a little.

It used to be rare to hear about ethics violations in pharmacy practice. Lately it seems to be a common occurrence.

Admittedly, part of the reason for the perceived increase in ethics violations today is that information is so quickly and readily available. One hundred years ago, it took a week to find out that somebody died, let alone that old Charley the druggist was selling paregoric on the sly.

But this doesn’t account for all of it.

Does the shoe fit?

Ethical behavior is a subjective issue. We all have stories about pharmacists who bend the rules, as well as stories about things we have done that might not look so very good if exposed to the light of day - things like:

• Scraping the word “sample” off birth control packages and selling them

• Jacking up the price of a prescription for difficult patients

• Dropping pills on the floor and invoking the five-second rule

• Telling a patient we are out of one of the ingredients for a compound, so we don’t have to make it

• Selling a little too much terpin hydrate with codeine

• Selling syringes, against our better judgment, to avoid a hassle

• Moving “important” customers to the front of the line

• Taking a pill out of stock because we forgot our dose

• Taking pills that we do not have a prescription for

• Writing our own prescriptions

• Allowing practitioners such as dentists and optometrists to write prescriptions for themselves or their family members for drugs that are not within their scope of practice

While none of these acts would earn us a spot on death row, most of us would agree that they are ethically wrong.

On the other foot …

Our employers have their own ethical issues, some hidden and some all too apparent. Consider these recent events:

• In Ontario, Canada, in the spring of 2013, a catastrophic medication error resulted in 1,200 cancer patients at five hospitals receiving weaker than standard chemotherapy doses over the course of a year, after Medbuy, the company that arranged the purchase of the chemotherapy solutions from supplier Marchese Health Solutions, neglected to specify the required concentration of medication to Marchese.

The bags contained too much saline, which may have been the reason that the prices from Marchese were so much cheaper than the prices of Baxter, the former manufacturer used by Medbuy.  A pharmacy assistant eventually detected the difference.

The Canadian legislature is currently reviewing the case.

• In July of 2013, Walgreens agreed to pay $80 million to settle federal charges that it failed to control the sale of controlled substances in its Jupiter warehouse and in its retail outlets in Florida and other states.

In conjunction with this same investigation, which began in Sept 2012, the DEA revoked the DEA registrations at two CVS Pharmacies located in Sanford, Fla.

• In July of 2013, an Indiana pharmacist was sentenced to 25 months in prison and Walgreens was fined $1.44 million for HIPAA violations resulting from disclosures the pharmacist made to her husband about a customer with whom he was previously involved. The husband then used this information to harass the plaintiff in an attempt to avoid paying child support payments for a child he had fathered. [See editor's note, below.]

• In December of 2013, it was reported that over 700 illnesses and 64 deaths in 20 states resulted from a fungal meningitis outbreak caused by tainted steroid injections. The source of the contaminated product, the New England Compounding Center, agreed to a preliminary settlement that would create a $100 million fund to compensate victims.

• On March 10, 2014, the LA Times reported that CVS Caremark is facing up to $29 million in fines for allegedly losing track of 37,000 hydrocodone pills at four California stores. They may have been sold on the black market.

• On March 30, 2014, TheIndianapolis Star reported that William J. Cover, former president and current board member of the Indiana State Board of Pharmacy, used his position to help gain approval for a controversial Walgreens pharmacy model it calls “Well Experience.”

These incidents are disturbing, because they cross the line from human error into negligence, intentional deception, and lack of ethics in business and professional practices. In a business where patients depend on the integrity of the company and its employees to safeguard their health and wellbeing, these acts are particularly heinous.

Speaking of the company …

Employers also seem to be crossing the line in their treatment of the people who work for them. The current treatment of employees in general is deplorable by any ethical standard.

In retail establishments, cashiers, photo specialists, managers and assistant managers, pharmacy techs, and pharmacists all are subjected to long hours, unpredictable schedules, abuse from their managers, abuse from the general public, dirty and unsafe working conditions, and, in all cases but those of the pharmacists and some of the managers, low wages.

Hospitals have similar issues, expecting top-notch service at bargain-basement prices from employees whom they guilt into extra shifts covered by bare-bones staff, all the while citing the importance of providing “excellent patient care.”

The people who are good at these jobs are by nature caring, trustworthy, hard-working individuals who want to contribute to society and help other people. It is easy to convince people with these characteristics to work harder for the greater good, while accepting less than adequate compensation for themselves.

Constant threats

These days, it is not enough for workers to show up on time and do their jobs. All too many endure the constant threat that hours will be cut, people “let go,” and stores closed if employees do not routinely go above and beyond the call of duty.

Employers behave as if they are paying top dollar to employees who work in rewarding “careers,” when in fact they are paying as little as possible for jobs nobody in their right mind would take, if there were any better jobs out there.  

Age bias

The forced elimination of workers in the 50-and-over age group, some of whom have 10 to 30 years with the company, is another disturbing trend. In the past, if these employees were not able to churn out as much work as their younger co-workers could do, their experience and knowledge were viewed as an acceptable trade-off.

These informal mentorships often involved some friction; the older workers could be irritated with the “young pups” who thought they knew it all, and the younger workers might resent the “old geezers” who couldn’t keep up and couldn’t remember anything. But in most cases there was a grudging respect from both parties, and an understanding that this was how the torch was passed.

In recent years, it seems, their higher pay and benefits have made older employees less desirable to employers. Too many are now rewarded for their years of dedicated service by being targeted and forced out through coercion, deception, lies, slander, and humiliation.

Apparently anything goes in the current corporate environment, even if it is illegal, immoral, and unethical. There are no more gold watches these days.

In the May 2014 edition of the AARP Bulletin (http:// bit.ly/agebiasAARP), Carol Fleck profiles five individuals who have suffered age bias on the job. In her article “Forced Out and Fighting Back,” she states,

“The signs at first are disguised, then painfully apparent, they say. Solid performance reviews suddenly turn negative. Invitations to weekly and monthly meetings are no longer forthcoming. New demands and quotas seem harsh and unreasonable. In what some see as age bias, older workers are being forced out of their jobs.”

At the end of the article, Fleck suggests contacting the Equal Employment Opportunity Commission (www.eeoc.gov; 800-669-4000), and the National Employment Lawyers Association (www.neia.org). She also mentions a resource guide about workers’ rights issues that is available at www.workplacefairness.org. To send Congress a message to protect older workers, go to www.aarp.org/fightback. 

When work does not pay

In the current economy, it is understandable that efficiency and cost control are priorities for profit-centered organizations.

What is unethical is the lack of respect, the mental and verbal abuse, and the manipulation of employees (most of them low-wage workers) imposed in the cause of generating huge profits for corporations, CEOs, and stockholders. 

Consider this, from the book The betrayal of work: How low-wage jobs fail 30 million Americans, by Beth Shulman:

“Why should we care that over thirty million Americans and their families face these conditions? We should care because it is morally repugnant. In a nation as rich as ours, where CEOs make four hundred times the average rank-and-file worker, leaving workers without the basic protections of life should be unthinkable. While one can argue that certain individuals should receive larger rewards than others for their contributions to society, it is quite another story to leave those who have worked hard without even the minimal necessities.

Allowing these conditions to continue challenges our notions of basic equity and fairness as these workers play by the rules and get so little in return. It erodes our most cherished values of personal responsibility, hard work, and perseverance. It sends the message that work does not pay.”

We all know technicians and cashiers, assistants, and managers who can always be relied on, who do their jobs with integrity, humor, and grace, who show up no matter what, and who treat us with respect.

Some of these same employees work two or more jobs, have difficult situations at home, have to share one car or have an unreliable car, and work all the extra hours they can, but still can’t make a living wage.

How shameful is it that some of our techs are on Medicaid, have to rely on relatives or live-ins for child care, have to worry about their utilities or phone service being cut off, and increasingly fear being laid off?

Do you care?

In the tradition of “The Ethicist” Randy Cohen, columnist for the New York Times Magazine, who published a collection of his columns in his book The good, the bad, and the difference: How to tell right from wrong in everyday situations, I turn this article over to you, the reader.

Consider the following ethical dilemmas:

1.     The store manager is adamant about having the drawers counted down and employees out the door by 10:30 pm. A patient fresh from the ER shows up at the drive-thru with five prescriptions at 9:55 pm. Do you fill them and deal with the manager’s reprimand, or send the patient to a 24-hour pharmacy 30 minutes away?

2.     A local dentist calls and asks you to refill his wife’s thyroid medication, which is out of refills. When you tell him this, he gets angry and asks to speak to your pharmacy manager, who “always does this for me.” Do you continue the tradition?

3.     One of your techs, who has been with you through thick and thin, starts to slip a little. These lapses have become more frequent lately; they are starting to affect your ability to focus on your duties and keep your patients safe. Furthermore, the other techs are complaining that this person is not pulling her weight and is causing more work to fall on them. Do you confront this issue head on, or ignore it and hope it will go away?

4.     One of your technicians tells you that a relief pharmacist often employs the “five-finger discount” at the end of the night, ringing up his own purchases and paying a suspiciously low price for a huge cartful of merchandise. Do you confront him?

5.     One of your technicians has admitted to abusing alcohol and drugs. This tech has also used the pharmacy drive-thru while impaired, bothered the staff and pharmacists at work and at home while heavily intoxicated, and shown up at work impaired on more than one occasion. When sober, however, she is one of your better techs, and you know she needs the job. Should you let it slide?

6.     You are asked to sell pain medication more than two days early by a patient who is known to you and has no history of abuse, a direct violation of the Good Faith Dispensing Policy. Do you use your professional judgment and take care of the patient? Does your answer change if the patient is a prominent local physician?

Now it is your turn. You can respond to the scenarios outlined above, or post your own questions or comments. You can give your name or post anonymously. Let go of some of your fear and speak up.

We have been silenced by the threat of losing our jobs, our profession, and our reputations. Some of us have already lost those things. What are you waiting for?

[8-5-2014: Editor's note: After reading this article, sharp-eyed reader Dave Franks wrote in to say that the author had inadvertently conflated two different news stories, one in which a Walgreens pharmacist in Kentucky was sentenced to 25 months in prison in February 2013 for identity theft, and a later one in which a Walgreens pharmacist in Indiana was involved in a  HIPAA-related case but did not receive a prison sentence. Here are links to the two stories: http://healthitsecurity.com/2013/02/18/walgreens-pharmacist-patient-data-breach-raises-questions and http://healthitsecurity.com/2013/07/29/walgreens-fined-1-44-million-for-pharmacist-data-breach. Our thanks to Dave for setting the record straight.]

Kim Ankenbruck is a pharmacist in Indianapolis, Ind. Contact her at kim.ankenbruck@yahoo.com.