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CONFERENCE REPORTS

Conference reports
Researching the chemists: towards an
integrated research agenda
Joy Wingfield
Health care law and ethics research has for some time
focused on the activities of doctors, nurses and other ‘hands
on’ clinical health professionals. But now there is a new kid
on the block – the pharmacist. Pharmacists working in hos-
pitals and primary care organizations are part of the NHS
‘family’, but what of their colleagues who work in other set-
tings – the community pharmacy or chemist shop? Their
role is changing rapidly and this raises many issues about
law, ethics and professionalism in a commercial setting.
One of the first questions to ask is how the training of
all pharmacists should be developed to prepare them for
the growing legal and ethical challenges of their future
practice. Since 1992, Professor Joy Wingfield and partners
have directed a government-funded project (APPLET, see
Box 1) to create teaching resources to assist practice
teachers in schools of pharmacy in enriching and broad-
ening the scope of the professional law and ethics covered
in the pharmacy undergraduate curriculum. As a spin-off
from this work, APPLET sponsored a one-day conference
in Manchester, with the aims of:
● raising awareness of developments in pharmacy
amongst the wider health care law and ethics research
community;
● raising awareness amongst pharmacy practice
researchers of research being undertaken in health
care law and ethics; and
● stimulating ideas for research directions and collabo-
rations.
Conference content
The four-part programme for the day was designed to
explore as many angles as possible on the topic in the
morning sessions and gradually collate and refine ideas for
future work in the afternoon. The first session, called ‘I’m
paying; just give me what I want’, comprised the views of
three experienced academics in the world of health care
law and ethics, who gave their perspectives (within the
brief of being reasonably thought-provoking) on those
who use community pharmacy services.
Professor Margot Brazier of Manchester University
kicked off by challenging how far health professionals
have a responsibility to protect consumers of health care
from themselves. Using a colourful personal analogy – buy-
ing herself a thoroughly inappropriate and revealing dress
– she questioned why community pharmacists felt they
should intervene to prevent inappropriate supplies of
medicines. At what point do pharmacists distinguish
between the character of their users as customers, clients
or patients? How do the commercial concepts of ‘the cus-
tomer is always right’ and caveat emptor fit with a profes-
sional duty of care and a presumption that patients may
need protection? Professor Brazier suggested that the phar-
macy profession itself was sending mixed messages: the
Code of Ethics both exhorts pharmacists to be aware of
and take action to prevent misuse and abuse of medicines,
and gives full recognition to patients’ rights to take part in
decisions and presumably be allowed to make their own.
Professor John Harris (CSEP Manchester University)
followed this with his customary challenge to accepted
thinking. We all agree, he said, that human enhancement
is a virtuous goal, so why is the use of ‘chemical improvers’
frowned upon – even though we are all encouraged to buy
glasses to improve failing sight? Professor Harris argued
against restraints on the availability of ‘lifestyle’ drugs, or
any drugs at all, assuming the risks are known and
accepted. Why should body builders not be able to acquire
anabolic steroids to enhance their physiques when the
concentration of children is treated with Ritalin
(methylphenidate HCl), sleep disorders associated with
shift working are treated with Provigil (modafinil), and
combat troops are routinely issued with amphetamine-type
drugs to overcome fatigue and exhaustion in battle? All of
these situations could be said to be enhancing life rather
than correcting an impaired life: where lies the distinction?
Issues surrounding mental health and capacity
amongst patients and consumers in the community were
addressed by Professor Peter Bartlett (Nottingham).
Focusing principally on the impact of the Mental Capacity
Act, Professor Bartlett questioned what role, if any, phar-
macists might have in the application of advance direc-
tives – or even the processes of assisted dying, if they
became lawful. Less sensationally, he raised issues concern-
ing the medication of patients who are housebound, in

Box 1 The APPLET Project

APPLET stands for Advancing the Provision of Pharmacy Law and Ethics Teaching. The project extends to teachers of professional
aspects of law and ethics in all schools of pharmacy in the UK and has developed teaching resources – a consensus curriculum,
supporting DVDs and web streams, sample lectures, workshops, teaching notes, assessments, references, bibliography, etc. – for
them to adopt or adapt for their own teaching purposes.
Joy Wingfield is Director for the APPLET Project, in partnership with Keith Wilson from Aston and Sandra Hall from Aston and De
Montfort Schools of Pharmacy. APPLET was fully funded by an award from the Higher Education Funding Council for England from
2002–2005 and now has further funding during 2006 to extend its work to new schools of pharmacy that have opened since 2002.
Further information on the project, including details of this researcher conference and other events, can be found on
www.nottingham.ac.uk/pharmacy/applet.

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Conference Reports 43

care homes or in prisons. How should pharmacists judge
the capacity of such individuals, and how familiar are they
with the closer legal parameters on determination of their
‘best interests’? In such situations, community pharmacists
regularly deal with patient proxies such as home helps, rel-
atives, neighbours, care workers and prison officers: to
what extent are they expected to inquire more directly
into the care of the patient?
After a few questions to each speaker, the morning
continued with three parallel discussion groups using facil-
itators with specialist expertise to prompt new directions
for enquiry into the work of the community pharmacist.
Dr Paul Bissell prompted thoughts on ‘Re-professionalizing
community pharmacy’, Catherine Hale led a discussion on
the impact of new prescribing roles for community phar-
macists, and Andy Crane challenged his group to consider
issues concerning the delivery of health care in a commer-
cial environment.
In the afternoon four pharmacists gave short reports
on their own research work: ‘Professional Autonomy and
Decision Making’, Zuzanna Deans; ‘Ethical Passivity and
Community Pharmacy’, Richard Cooper; ‘Patient Welfare
and Community Pharmacists’, Ailsa Benson; and
‘Pharmacists and Confidentiality’, incorporating privacy in
community pharmacies, Sue Melvin.
Research directions and themes
A full hour at the end of the programme was devoted to col-
lecting and collating the thoughts of all participants on
what questions had been raised in their minds and what
research themes or areas might be suggested for future exam-
ination (Table 1). These are perforce crude and incomplete,
but they are perhaps the first attempt to bring together the
perspectives of non-pharmacists as well as pharmacists upon
the professional legal and ethical challenges of expanding
community pharmacy practice. One participant suggested
that scope exists immediately to compare and contrast the
situation of community pharmacy with relevant findings
from existing health care law and ethics research and studies
in related professions (e.g. financial services, engineering
and the law). Another cautioned against undertaking stud-
ies of consumer perspectives on the role and culture of com-
munity pharmacists without also identifying what would be
done with such information. A third suggested that philo-
sophical rather than empirical research should be the start-
ing point to characterize whether and how pharmacy differs
from medicine or nursing.
One conclusion came through very strongly: that the
participants found the day stimulating and refreshing
(even ‘exciting’ for one contributor); that further days
should be undertaken to refine and improve the framing of
research questions to pursue; and that publication of the
conference proceedings might stimulate contributions
from a much wider community to assist in this process. I
hope to hear from you!
If you would like to contact Joy Wingfield and find
out more about her work in this field, please do so via
email at joy.wingfield@nottingham.ac.uk

Table 1 Researching the Chemists – Themes and Questions

Theme Questions

Philosophical context Why are medicines treated differently from chocolate?

To what extent, and how, does the legal and ethical context of pharmacy practice differ from medicine or
nursing?
To what extent, and how, does the legal and ethical context of pharmacy practice differ from other
professions in a commercial setting such as the law or financial services?
How relevant is existing research on medical and nursing ethics to the practice of community pharmacy?
How should pharmacy ethics engage with health care ethics?
How do we understand the professional socialization of community pharmacy and the increasing
routinization of pharmacy work tasks? How does this impact on the professionalization agenda?
What are the barriers to re-professionalization of community pharmacy?

Knowledge base of
community pharmacists
What do community pharmacists already know about key health care law and ethics concepts such as
confidentiality, capacity and consent?
To what extent are community pharmacists familiar with the principles and application of different forms
of law (civil, criminal, administrative, professional)?
How do community pharmacists perceive the ethical principles behind and purpose of the laws within
which they operate?
How do community pharmacists manage confidentiality issues for the one third of prescriptions that are
not presented by the patient?
Should community pharmacists have full access to medical records? If not, why not?
How do community pharmacists establish consent to vaccinate for influenza or test for sexually
transmitted infections in a retail setting?

The effect of corporatization
of community pharmacies
What are the benefits and disadvantages of the growth of multiple ownership in community pharmacy?
To what extent do the priorities of multiple pharmacy owners map on to the goals of the NHS and
individual pharmacists?
What effect does multiple ownership have on the extent of professional autonomy/duty of care to the
patient for community pharmacists?
What is the role and impact of non-pharmacist managers on the work of community pharmacists?
How does decision-making at corporate level affect individual decision making by community
pharmacists?
Who are the stakeholders in the success of multiple pharmacy owners and how are their needs met?

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44 Conference Reports

Table 1 continued

Theme Questions

The relationship between
community pharmacists and
patients in institutional care
To what extent do residents in care settings retain autonomy over their medication?
When community pharmacists supply care homes, what are their responsibilities to ensure appropriate
management of the medication for residents?
When supplying prisons and similar establishments, what are the responsibilities of the supplying
pharmacists?
What are the views of residents, prisoners, social workers, key workers, pharmacy owners and care-home-
owners on medication needs in institutional care?

Community pharmacists,
pharmacies and
pharmaceutical companies
What are the views of community pharmacists on the legal and ethical restraints on the advertising of
medicines?
How do community pharmacists deal with the controversy over animal rights and the testing of drugs in
animals?
How can the relationship between pharmaceutical companies and pharmacy ownership be
characterized? How are the views and practices of community pharmacists affected by this relationship?

Balancing paternalism and
autonomy across
a spectrum of users
Is the paternalism of community pharmacists justified in relation to their specialized knowledge of the
danger of medicines?
How does the growing lay expertise of patients affect the scope of paternalism in community
pharmacists?
What is the ethical basis for the limitation of the sale of medicines by community pharmacists?
How will the revision of personal control and supervision law affect the relationship between community
pharmacists and their users?
What are the implications of dealing with consumers rather than patients?
Do users of community pharmacies want health promotion advice when they shop in a community
pharmacy?

Legal and ethical
responsibilities within teams
To what extent should community pharmacists be accountable for the efficacy of the medication they
dispense?
How has the development of non-medical prescribing affected the role of community pharmacists?
What new risks and accountabilities are created by the advent of pharmacist supplementary and
independent prescribers?
To what extent do community pharmacists feel subordinate to the general practitioner?
To what extent should community pharmacists exercise religious or cultural reservations about the
supply of medicines associated with the beginning or end of life?

The environment of
community pharmacy
What are the benefits and disadvantages of practising community pharmacy in a commercial retailing
environment?
How do pharmacists balance conflicts of interest between the needs of individual patient and the needs
of the business?
How does a health care ethic based on a duty of care interact with a commercial ethic of cost-benefit
analysis?
To what extent does isolation and routine characterize the work of community pharmacists? What impact
does this have on their ethical awareness?
How does the design and construction of a community pharmacy affect privacy and confidentiality?

UK Clinical Ethics Network 6th Annual
Conference: Ethics and the vulnerable
patient. Held 11th May 2006. Hosted
by James Paget NHS Trust Clinical
Ethics Advisory Group
Anne Slowther
This was the 6th conference to be held by the UK Clinical
Ethics Network and the excellent attendance of over 100
delegates reflects the increasing interest in clinical ethics
in the UK. The conference provided an opportunity for
health professionals, ethicists and members of clinical
ethics committees to debate the particular ethical con-
cerns that arise in the treatment of vulnerable patients,
and to reflect on the nature of vulnerability in health care.
A key feature of all Network conferences is the thoughtful
discussion among delegates as well as speakers on the
issues raised, and this conference was no exception. The
day began with an illuminating presentation by Professor
Bobbie Farsides, Co-Editor of this journal. Bobbie explored
what we might mean when we talk about vulnerability and
reminded us that health professionals could also be vulner-
able. There followed three presentations looking at ethical
issues arising in different contexts of patient vulnerability.
The particular vulnerabilities of children were explored in
two presentations, one looking at management decisions
in very premature infants and the other at issues of auton-
omy in caring for adolescents. The third presentation
focused on primary rather than secondary care and consid-
ered the difficult decisions around end of life care from the
perspective of a nurse, a GP and a medical director of an
ambulance trust.
The afternoon session opened with a debate, the
motion being ‘This house believes that the GMC guidance
on non-consensual testing for HIV is in everyone’s best
interests’. This debate was prompted by a recent electronic
discussion between clinical ethics committees which iden-
tified some concern that current GMC guidance did not

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Conference Reports
take sufficient account of the rights of health care workers
in situations of needlestick injury. Dr Michael Wilkes,
Chair of the BMA Ethics Committee, spoke in favour of
the motion and Mr Michael Dusmet, consultant surgeon,
spoke against. The ensuing debate was extremely lively
and in the final vote the motion was defeated. The final
session took the form of a mock clinical ethics committee,
with a panel of committee members discussing cases sug-
gested by delegates in advance. This session generated
wide-ranging discussion of a number of ethical issues and
provided an insight into the challenges facing committees
and clinicians in day-to-day practice.
Overall, the conference was a great success and may
well have sown the seeds for the development of further
clinical ethics committees over the next twelve months.
The 7th annual Network Conference will be held in
Portsmouth on 22 May 2007. For further details contact
admin@ethics-network.org.uk or visit www.ethics-
network.org.uk. Anne Slowther can be contacted at
a-m.slowther@warwick.ac.uk
Report of the Maastricht meeting of
the European Clinical Ethics Network
Bert Molewijk and Guy Widdershoven
The European Clinical Ethics Network (ECEN) was set
up in 2005 by Veronique Fournier (Paris), Bert Molewijk
and Guy Widdershoven (Maastricht) in order to share
both clinical and research experiences regarding clinical
ethics consultation and clinical moral case deliberation.
The increasing prominence of these activities within the
domain of clinical ethics necessitates transparency and
improvements with respect to theory, methodology, qual-
ity and results. The ECEN is a small working group
within which European countries are represented, and it
meets twice a year. This brief report describes the second
meeting, which took place on 12–13 May 2006 in
Maastricht, the first meeting having been organized in
November 2005 at Veronique Fournier’s Centre
d’Ethique Clinique Hôpital Cochin, Paris. It is hoped
that Clinical Ethics will provide a useful platform for
future work of the Network.
45
The purpose of the 2006 meeting in Maastricht was to
establish a more detailed insight into how different clini-
cal ethicists actually work when they are involved in a
moral case.
The following members of the ECEN presented cases
to the group: Jochen Vollmann from Germany, Veronique
Fournier from Paris, Anne Slowther from the UK, Anna
Borovecki from Croatia, Larry Schneiderman from the
USA (guest visitor) and Bert Molewijk from the
Netherlands.
To make subsequent discussion more concrete, a set of
questions was developed as a guideline for the discussion
after each presentation. To make the comparison between
the European members even more explicit, a grid was devel-
oped wherein all the different approaches (on a single case
basis) were compared. The grid recorded, among other
things: who initially submitted the case, the time and place,
the participants involved, the goals of the case consulta-
tion/deliberation, the method and structure of the consulta-
tion/deliberation, the normative dimension of the ethicist’s
role, the consequences of the case consultation/deliberation,
the recording of proceedings, and any follow-up.
The structured use of single concrete cases gave us a
detailed insight into the way the different European mem-
bers work, how the consultation or deliberation process is
organized, and which underlying presuppositions regarding
consultation or deliberation exist. The use of the grid
informed us of the differences and similarities with respect
to focus on process versus outcomes, the normativity of
the ethicist, the (lack of) patient involvement, the meth-
ods of consultation/deliberation, and the way in which we
monitor or evaluate the quality and results of our work.
Bert Molewijk and Guy Widdershoven are part of the
Moral Deliberation Group, University of Maastricht. If
you are interested in finding out more about the ECEN,
please contact Bert Molewijk by email at
B.Molewijk@zw.unimaas.nl
The Ethics Department of the Dutch Ministry of
Health partly supports the ECEN financially. The secre-
tariat of the ECEN is hosted at the Moral Deliberation
Group of the University of Maastricht: for more informa-
tion, contact moreelberaad@zw.unimaas.nl.
Clinical Ethics 2007 Volume 2 Number 1