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The pharmacist's role in patient care.

Richard M. Schultz, associate Professor of pharmacy practice, College of pharmacy, University of South Carolina, Columbia; David B. Brushwood is professor of pharmacy health care administration College of Pharmacy, University of Florida, Gainesville.

The role of the pharmacist is frequently omitted from discussions of patient care issues, where the focus is on the physician and other health care providers within the physician's immediate sphere of influence. When attention does turn briefly to pharmacists, confusion often arises about the scope of their responsibilities to the patient and the expectations patients should have of them. Similarly confused views of pharmacy are frequently seen in newspaper articles and judicial opinions.[1]

A factor that may contribute to confusion about the role of pharmacists is that observers of health care trends tend to be autonomous decisionmakers, who in their personal lives have little need for the information and counseling that are valued highly by less sophisticated pharmaceutical consumers. Well-educated, high-income policy makers can be their own advocates. They are not likely to leave a doctor's office without a thorough explanation of a drug's beneficial and detrimental effects. Less fortunate and less assertive individuals may have greater need for a pharmacist's assistance with drug-related medical decisions. Class differences between patients and physicians may stifle interaction if physicians withhold information that they consider too technical and detailed for certain levels of understanding or if patients remain silent for fear of appearing ignorant or being a nuisance. Pharmacists frequently live and work in the same community as the people they serve, and are often closer in socioeconomic status to patients than are physicians. Patients, therefore, may view pharmacists as more approachable about health issues.

We suggest that the public would be well served if pharmacy practice expanded into new areas, including patient advocacy. Legal scholars, ethicists, and health care analysts must consider whether such expansion should be encouraged. Critical questions shaping this consideration should be: (1) Do physicians currently provide patients with sufficient risk-related information about drugs? (2) Do pharmacists possess sufficient knowledge of drugs and diseases to counsel patients competently in the physician's absence? (3) Is the pharmacist an appropriate person to serve as a patient advocate with respect to drugs? (4) Does pharmacists' providing patients with accurate information about drugs necessarily interfere with the Physician-patient relationship? (5) Is a risk assessment/risk management conceptualization sufficiently rich and flexible to accommodate emerging health care roles? (6) When, if ever, is a pharmacist justified in withholding information from a patient? and (7) Can pharmacists work legally and ethically with a patient to develop an optimal medication practice for that patient if the medication practice might differ from the directions for medication use given by the physician?

Stages of Assessment:

During the past several decades, there has been a trend in drug therapy toward centralized decisionmaking, with fewer and fewer options being left to the person whose body is to be affected by the drug. New drugs must be approved by the Food and Drug Administration (FDA) before they are marketed, and most effective drugs must be prescribed by a physician. A patient does not have the freedom to decide to use a chemical substance as a medication unless the FDA has first approved it and a physician has prescribed it.

The drug distribution system, although rigid in some respects, is sufficiently flexible to accommodate risk evaluation at three stages. The first stage is the negotiation between a new drug's industrial sponsor and the FDA. In deciding whether to approve a new drug, a scientific assessment of risk is made, based on known characteristics of a general population. When a physician prescribes a drug, a second stage of risk evaluation occurs through clinical assessment of the particular patient's physiological idiosyncrasies, resulting in a decision regarding the suitability of an approved drug for that patient. A third stage of risk evaluation occurs every time patients administer drugs to themselves, when a personal assessment of risk is based on personal circumstances and attitudes. Patients may choose to avoid a risk by not using a drug, or to manage a risk by modifying their habits to decrease the probability that an adverse effect will occur. Through patient advocacy, pharmacists can assure that decisions made at this third stage are as informed and as valid as those made earlier.

Those who are empowered to distribute drugs generally adopt the traditional view that people appreciate being denied the liberty to choose a harmful or ineffective drug. When the FDA decides that a drug is not safe or that it is not effective, that decision has a direct impact on future sufferers of the disease the drug is intended to treat. Within the system, state paternalism operates to make certain drugs illegal and severely controls access to others under the assumption that people need to be protected from their own poor decisions.

Establishing broad guidelines and indications for use of drugs constitutes a justifiable paternalism. Society grants the medical and scientific community the mandate to develop and make available drugs that are good for us. At these stages of risk assessment, then, paternalism is appropriate.

Although there are still decisions to be made about drug risks at the later stages, there may be a tendency to believe that questions about safety and efficacy have already been resolved. Here paternalism is inappropriate, yet it is still frequently practiced.[2] The scientific evaluation made by the FDA and the clinical assessment made by the physician are incomplete in the absence of a personal evaluation of risk by the patient. Pharmacists, who have extensive knowledge of the effects of drugs and often know a patient's medication history, are accustomed to thinking of the physician and the FDA, not the patient, as the decisionmakers on drug risks. They assume that once a prescription is written there is no longer room for discretion or judgment.

Models of Pharmacy Practice:

Pharmacists traditionally have functioned as mechanical prescription processors, typing labels and counting pills. Within this technical model, voluntary actions may be taken for the benefit of patients if time and circumstances permit, but the pharmacist's primary activity is oriented toward the product rather than the patient.

The developing clinical model of pharmacy practice goes a step beyond the technical model to include promoting "rational" drug therapy. Clinical pharmacists are considered to have a professional duty to encourage compliance with what the doctor has determined to be the appropriate use of medication. This usually includes emphatic assurance that the doctor knows what is best. Although the patient may be interacting with the pharmacist more than before, the patient is still not considered a decisionmaker with respect to his or her drug therapy.

We believe, however, that pharmacists must begin to function as extensions of patients, not of physicians. Being patient-oriented in a modern health care context involves respecting patient autonomy.[3] A patient-oriented pharmacist would be an advocate with regard to all matters concerning medication, assuring that the patient is making decisions based on a clear understanding of risks and options, and that the patient's own values, lifestyle, environment, and personal attitudes toward risk are respected. The patient's decisions need not be viewed as "correct" from the objective view of the health care provider, but rather as "appropriate" from the patient's subjective view.

The Pharmacist as Patient Advocate:

While nurses serve as patient advocates, especially in the hospital setting, the patient has no advocate in the community setting, particularly with respect to drug-taking decisions.[4] Yet these are the medical decisions in which the patient has the greatest degree of independence. Initially, the physician and patient assess risks and benefits of drugs prior to prescribing; but risk assessment continues each time the patient, taking the medication, decides the benefit of the drug exceeds its risks. In this sense, unsupervised use of medication is self-treatment, with the patient self-monitoring for positive and negative outcomes. The entire system of drug distribution, whose risks are assessed very carefully at the first two stages, can be undermined by a careless or uninformed decision on the part of the patient. The failure of pharmacy to embrace a true patient orientation prevents it from serving as an advocate for careful decisions at the stage of self-administration.

The argument for pharmacists' assuming a true patient-oriented ethic follows three distinct paths. First, the need exists for someone to function in this capacity. The drug-delivery system and its players have maintained a paternalistic approach to patient care, yet in spite of well-meaning efforts on the part of physicians, pharmacists, nurses, third-party payers and others, patients will experiment with prescribed drugs.[5] Several empirical studies have suggested that physicians are not involving patients fully in decisions about drug use. Ruth Faden and colleagues report that physicians routinely disclose less detailed information than patients want to receive, as well as disagreeing about the consequences of this lack of information. Physicians also provided little information about alternative therapies.[6] A national study by Louis Harris and Associates reports a large discrepancy between the proportion of physicians who say they usually discuss diagnosis and treatment with their patients and the proportion of the public who report they usually receive this information from their physicians.[7] Although physicians often do not realize it, patients almost always want as much information as possible.[8]

Failure to include the patient in decisionmaking is evidenced in the prescribing process. Worthen identified six variables that affect physician prescribing, with patients having only slight influence.[9] And John Lilja reported that once physicians gain experience with a particular drug, the prescribing process becomes habitual, suggesting that individual patient idiosyncracies, values, and preferences may not be a pan of the majority of prescribing decisions.[10]

The second argument for pharmacists' assuming a true patient orientation arises from the nature of pharmacy practice itself. Pharmacists are easily accessible in the communities where people live; they are recognized by the public as technically competent and considered to possess high levels of integrity; they are afforded a social trust generally given to friends, neighbors, and relatives.[11] Because many medications are used over a period of months or years, pharmacists can tell by a patient's pattern of obtaining refills whether the patient is using the medication according to the physician's directions. Frequently patients will assure their physicians that directions are being faithfully followed, yet their medication record at the pharmacy tells a different story. The common practice of authorizing refill prescriptions by telephone also means that while the physician is present during the initial decision to begin the medication, the patient's only personal contact with a health care provider over extended periods of time may be with a pharmacist. Given this combination of characteristics, it is appropriate that the patient view the pharmacist as an advocate in drug use decisions.

The final argument for pharmacists' serving as patient advocates arises from an emerging professional independence, similar to that found in nursing. Currently, three states have granted certain prescribing rights to pharmacists. Therapeutic substitution, the exchange of products within the same therapeutic class, has been supported by the American Pharmaceutical Association as a reasonable use of pharmacists' comparative knowledge of drugs. In addition, an expansion of the pharmacist's role to include patient counseling was part of the much-debated (and now repealed) Medicare Catastrophic Legislation. While it has been argued that pharmacists lack diagnostic skills and have insufficient knowledge of physiology and pathology to justify broadening their functions in such ways, they do possess extensive knowledge of drug characteristics and often come to know their clients over extended periods of time. These circumstances permit an appropriate expansion of patient-oriented activities.

We do not suggest that pharmacists are presently as qualified as physicians to evaluate the benefits and detriments of a given drug for a specific patient. Taking on the role of patient advocate does not grant pharmacists the right to diagnose, nor does it preclude communication with the physician. However, in a drug distribution system that respects patients' rights to participate in decisions about risk, we suspect that pharmacists would perform well in providing information and otherwise assisting with decisions. One of the unseen costs of any monopoly is that alternative methods are not readily considered. An alternative to physicians' monopoly on prescribing drugs that focuses on the pharmacist is worthy of consideration if only on the grounds of efficiency. Our model would make good use of the pharmacist's expertise and physical location, and it would address the problem of costly therapeutic failures that result when medication users are underinformed.

Potential Problems with Patient Advocacy: Several practical questions arise. First, how would other health practitioners be informed of pharmacist-patient exchanges and the patient's decision concerning drug use? Currently, pharmacy serves as the repository of information concerning drug distribution. Pharmacies are required by law to maintain records for many years on the type, strength, and quantity of every medicine dispensed under a prescription. Computer technology allows for rapid retrieval of all relevant information for each patient served. Patients' decisions about drug usage would be stored and retrieved by computer as well and made available on request to health practitioners involved in a patient's care. This process offers an advantage over the current system, where patients make decisions unilaterally or on the advice of friends or relatives. Under present conditions there is no means of recording or disseminating the relevant information, and health practitioners remain unaware of patients' actual drug-taking behavior. While patients may be disinclined to admit frankly to their physician that they have decided not to use the drug as "ordered," they might communicate with greater candor to an advocate who, literally, speaks for the patient.

A second and perhaps more compelling concern is the expected interprofessional conflict that could arise when a pharmacist serves in this capacity. The seeds of that conflict have been present all along. The debate over the pharmacist's professional and legal responsibilities in dispensing a medicine that the pharmacist believes would be harmful to the patient is of long standing. What should the pharmacist do if the physician requests that the prescription vial not be labeled and the patient asks the pharmacist the name and use of the medicine? Should a pharmacist breach patient confidentiality by providing information to family members and other health care professionals about a teenager's use of an abortifacient drug? Should a pharmacist dispense a medicine prescribed by a physician if the patient is abusing the drug? Can the physician demand that the medicine be dispensed? Although it creates the potential for increased conflict, the patient advocacy role for the pharmacist presents an opportunity for pharmacy to clarify the scope of its professional responsibility. While it may not be correct to assume that patient advocacy by pharmacists will always lead to conflict with physicians, it is important to recognize that conflict may produce beneficial outcomes, however uncomfortable the process may be. We do not contend that pharmacists should orient themselves toward patients without regard for the possibility that physicians may be upset by the threat to traditional authority, but conflict should not be avoided at all costs, particularly if one of the costs is an underinformed patient.

The potential for conflict is not limited to the physician-pharmacist relationship. Advocacy itself carries with it the potential for conflict. How forcefully should a pharmacist recommend and advise for or against a certain course of action? Can the pharmacist continue to support a person in a decision with which the pharmacist does not agree? The advocate's concern for the patient should remain grounded in respect for the patient's autonomy, rather than in beneficence. Veatch, contrasting the medical authority model with the value choice model of compliance, contends that beneficence does not always equate with doing the best thing for the patient.[12] Pharmacists as patient advocates ought for this reason to support patient decisions based on the patient's values and preferences, facilitating informed decision and respecting the patient's choice, regardless of whether it is consistent with prevailing scientific opinion.

This is not to say that patients always have the right to be fully informed about the benefits and detriments of drug therapy. A pharmacist has no duty to disclose information that may interfere with a rational therapeutic decision. The pharmacist may not withhold information because of concern that patients may reject prescribed drug therapy, as this construal of the duty to protect decisionmaking would permit physicians and pharmacists to substitute their judgment for that of the patient in every instance of medical decisionmaking. Information may not be withheld to avoid harm to the patient, but only when disclosure would harm the process of decisionmaking.

Thus, the patient who is being weaned from strong and potentially addictive narcotics has no fight to know that a newly prescribed drug is a weaker analgesic, if that knowledge would compromise that patient's ability to participate in a decision about the benefits and detriments of therapeutic options. The pharmacist should withhold this information, not because the patient may refuse the new drug, if known to be weaker, but because fear of pain could cause the patient to refuse to consider a nonaddictive alternative that may be equally effective. In this same vein, a pharmacist would have no duty to disclose information regarding the abortifacient effect of a drug, or the dose of a drug necessary to commit suicide, if the information were obviously going to be put to some other use than to improve the quality of a medical decision.

Patient Response to Advocacy:

Patient behavior may be described within the context of either the sick role espoused by Parsons or the need for autonomy developed by Conrad.[13] If a patient subscribes to the sick role, she or he will seek medical attention, viewing the diagnosis of the physician and the medication of the pharmacist as validation of the illness. The patient exercising autonomy will not be content with this passive role in dealings with these health professionals. Autonomous patients will seek to participate in their treatment by questioning therapy decisions made by the physician, suggesting alternative therapies, and even seeking second opinions on the diagnosis itself. According to Conrad, autonomous patients will develop their own medication practice, even though it may not coincide with the health professionals' recommendations. Much of this behavior could be seen as noncompliance, but from the patient's perspective it is not. People adjust their regimens to suit their life situation. They may be solving a problem that a particular drug or dosing schedule creates. They may choose to avoid the stigma of the condition that their medication represents. They may be lowering the dosages to see if their condition has improved. In effect, patients may alter their drug regimens in an effort to retain control.

Pharmacists routinely assist patients in obtaining the maximum benefit from the prescribed drug. They advise that the medicine be taken with meals, for example, or that the patient avoid alcoholic beverages while using a given drug. This pharmacist-patient exchange fits nicely into the sick role model, where the patient has the responsibility to seek professional care and follow the advice given. But can the pharmacist provide benefit/risk information to a patient while facilitating patient autonomy? As pharmacy is currently practiced, the answer is no. When a patient has altered the quantity or timing of the dosage and asks the pharmacist about it, the typical response will reflect the pharmacist's orientation to the physician: "You should take the medicine exactly the way the doctor prescribed it." The suppressed assumption is that the right to develop a medication practice is solely the physician's-a right the physician is not likely to extend to the patient. The physician has stated through the prescription what is deemed correct from the medical standpoint. The pharmacist is duty-bound to promote compliance with the prescribed regimen. This situation leaves the patient with no one from whom she or he can obtain information that will maximize the benefits and manage the risks involved in the decision to alter the way the medicine will be taken. The result is a patient who experiments with potent medicines without professional support.

Risk Assessment and Risk Management:

Pharmaceutical malpractice litigation has contributed a distinction that clarifies pharmacists' responsibilities: the difference between risk assessment decisions and risk management decisions.[14] Risk assessment is a highly judgmental process that occurs prior to prescribing. Since the use of a given drug often raises questions about personal values, lifestyles, and attitudes toward risk, physicians cannot make good decisions about prescribing the drug unless they consult with the patient In turn, patients cannot participate intelligently in the decision unless they receive information about the drug so that they can properly assess the risk to which they may be exposed.

One consequence of providing risk assessment information to a patient might be that the patient decides to forgo use of the drug. If this were to happen, the patient and the physician would select an appropriate alternative form of therapy. This process is often spoken of as informed consent, and traditionally it has been the physician, not the pharmacist, who has provided the initial assessment. The pharmacist's traditional role has been risk management. This is a nonjudgmental process that occurs after the prescription is made. It does not require an in-depth knowledge of every patient's medical condition, because the information conveyed relates primarily to characteristics of the drug, and can be given to all patients. No drug is completely free from the risk of certain adverse side effects, even if it has been determined to be the most appropriate form of therapy for a particular patient. Precautionary statements concerning proper drug use can lead to more successful therapy, and to early recognition of adverse effects.

Within the technical and clinical model, there is an identifiable role for pharmacists in the risk management decision. The patient advocate model, however, does not delineate the role so clearly. Some aspects of a pharmacist's behavior as advocate could best be categorized as risk assessment while others would be seen as risk management. The patient-advocate pharmacist would serve patients by providing objective information that would help them to create their own medication practice. That practice, which is the result of trade-offs and compromises patients make based on their own value system, may result in taking a medicine in a way that deviates from the prescription, or choosing among several prescribed medications on the basis of cost, perceived severity of side effects or therapeutic failure, or any other factor important to the patient. By informing the patient of the potential effects, both good and bad, of the prescribed therapy and the patient's departure from it, the pharmacist functions as a risk assessor. However, the pharmacist's role in risk assessment does not limit the options available to the patient, as currently occurs with the physician's decision to select one particular therapy. The pharmacist as advocate would assist the patient in assessing the risks and benefits of the patient's emerging medication practice without the negative overtones associated with noncompliance. This assistance could not be rendered if pharmacists maintained a physician-oriented clinical practice, where the only response possible would be that the prescribed therapy is "medically correct" and therefore must be followed.

The pharmacist as advocate would also assist the patient in risk-management decisions. After the patient has assessed the available alternatives and filtered them through his or her unique value system, the patient makes a decision concerning therapy. Once the decision is made, the pharmacist can help the patient reap the greatest possible benefit the choice permits. For example, because of work or other intervening circumstances, a patient may not be able to take a particular drug four times a day as prescribed, and may tell the pharmacist the medicine can be taken two times a day, at best. The pharmacist, drawing from knowledge of the drug's half-life and therapeutic index, could suggest ways to increase the drug's efficacy within the twice-a-day limit-by doubling the amount taken, for example, or perhaps by using a sustained release formulation of the drug. In this example, the pharmacist has used knowledge to fit the therapy to the person and not the person to the therapy.

Those who stand to benefit the most if pharmacists became patient advocates would be the disenfranchised, the poor and undereducated who tend to be passive when dealing with authority figures. Carroll and Gagnon report that pharmacists may already sense a special obligation to these individuals, as they counsel them more frequently than they do others.[15]

Review of Critical Questions:

This paper began with our posing several questions critical to any discussion concerning the role of the pharmacist in patient care. We hope the following summary response will serve as a springboard for further debate.

* Do physicians currently provide patients with sufficient risk-related information about drugs? There appears to be a discrepancy between the amount of risk-related information patients want and the amount that is routinely provided by physicians. Most physicians report that they make conscious and deliberate evaluations of how much to tell patients regarding their diagnosis, prognosis, and side effects of therapy. We do not speculate whether this discrepancy leads to untoward clinical outcomes. We do argue, however, that it may result in patients making decisions with less than full information.

* Do pharmacists possess sufficient knowledge of drugs and disease to counsel patients competently in the physician's absence? Pharmacists have the knowledge to discuss disease states in general, but do not have the knowledge to counsel individual patients concerning the progression of their specific disease. Pharmacists do have knowledge of how a prescribed drug works in the body, along with its concomitant benefits and risks. This knowledge is the contribution a pharmacist makes to patients as they develop their own medication practice.

* Is the pharmacist an appropriate person to serve as a patient advocate with respect to drugs? Our primary contention is that a need exists for a patient advocate with respect to drug use in the community setting. Pharmacists are appropriate persons to serve the patient in this capacity, owing to their knowledge of drugs, familiarity with the patient, accessibility to the community, and the esteem in which they are held by the public.

* Does pharmacists' providing patients with accurate information about drugs necessarily interfere with the physician-patient relationship? Many attempts to provide information "interfere" with this relationship, including television and the print media. Pharmacists, in providing accurate information, serve the patient better than these. Where the information is consistent with that provided by the physician, the physician-patient relationship is strengthened. Where the information is accurate and inconsistent with the physician's, or more complete, the physician-patient relationship may suffer. Advocacy interferes with a physician-patient relationship to the degree that the relationship prevents individuals from making informed decisions. Although the physician-patient relationship is important, it should not be given primacy over the process of informed decisionmaking.

* Is a risk assessment/risk management conceptualization sufficiently rich and flexible to accommodate emerging health care roles? Patient advocacy would be an expansion of pharmacists' traditional duties, and would move pharmacists into assessing as well as managing risk. Pharmacists would explain the choices open to patients regarding drug therapy, as well as the consequences of a given choice. The framework remains fully explanatory. What is challenged is the belief that pharmacists should limit themselves to risk management.

* When, if ever, is a pharmacist justified in withholding information from a patient? Disclosure of recognized but remote risks that are unlikely to materialize is not justifiable when the confusion and fear resulting from disclosure would impair a patient's ability to participate rationally in a medical decision. When a pharmacist believes that the information will serve no useful purpose, and in fact may be harmful to the process of deciding, it is justifiable to withhold the information. Concern about bodily harm to the patient may not be used as an excuse for a general policy of nondisclosure. The objective of disclosure is to improve the quality of decisions about drug risks through patient participation, and nondisclosure is justifiable only when providing the information would frustrate this objective.

* Can pharmacists work legally and ethnically with a patient to develop an optimal medication practice for that patient if the medication practice might differ from the directions for medication given by the physician? Professional practice both influences and is influenced by legal decisions related to it. One can argue that pharmacy has not embraced an advocacy role because courts have not seen pharmacists in that light, and have given no indication they will do so. However, courts respond to the facts of any case against the backdrop of prevailing professional practice. Without evidence of such a role, courts will not speak to it. The circular nature of this arrangement is one reason why roles evolve slowly.

Currently, a pharmacist functioning as a patient advocate may be viewed as practicing outside the boundaries of pharmacy if the advocacy causes the patient to turn away from the physician's directions. The irony, and perhaps the root of the ethical dilemma for pharmacists, is that the patient will develop a unique medication practice with or without the pharmacist's assistance, possibly to the patient's detriment. The extent and consequence of drug misuse supports this contention. By helping to promote the patient's autonomy, the pharmacist may also be able to save the patient from harm.

Final Comments:

The drug distribution system, as it is currently structured in the United States, leaves little room for involvement by the pharmacist. The physician holds the key to the medicine chest. Other caregivers-and patients-are expected to follow the physician's lead. Pharmacy has been physician-oriented because everyone has been physician-oriented. But Conrad's self-regulatory model of patient compliance suggests that the patient is the primary decisionmaker. While self-regulation by patients is currently viewed as aberrant and irrational, it continues to exist, and is probably inevitable given the current restrictions on the drug distribution system. If the system were restructured to permit a higher level of pharmacist-patient interaction within the system rather than outside of it, then the pharmacist could be useful as a source of information and as an advocate for the patient.

As the pharmacy profession continues to wrestle Kith the problems of unrealized potential, ethicists and other health care analysts have a choice to make. They can either continue to omit the pharmacist from discussions of patient care issues, or they can help develop a new role for pharmacists by explaining what society expects of the profession.

References:

1. See Washington Post editorial, "Dear George....," 8 October 1987; and Washington Post, George Will editorial, Judge Bork and Sensitivity Snobbery," 8 October 1987. See also follow-up letter to the editor, "Erroneous Description of Pharmacy," Washington Post, 14 October 1987. See Jane Brody's column "Personal Health" New York Times, 11 February 1988, p. A14; Ingram v. Hooks Drugs, Inc., 476 N.E. 2d 881 (Ind.App. 1985); Riff v. Morgan Pharmacy, 353 Pa.Super. 21, 508 A2d 1247 (1986).

2. Lawrence B. McCullough, "An Ethical Model for Improving the Patient-Physician Relationship," Inquiry 25 (1988); 454-68.

3. See Peter Conrad, "The Meaning of Medications: Another Look at Compliance," Social Science and Medicine 20 (1985): 29-37; and Peter Conrad, "The Noncompliant Patient in Search of Autonomy," Hastings Center Report 17, no. 4 (1987): 15-17.

4. Winifred Pinch, "Patient Advocacy, Ethical Dilemma and Decision Making: The Importance of Autonomy," Imprint 32 (1985): 36-39.

5. J. F, Cooper, D. W Love, and P. R. Raffoul, "Intentional Prescription Nonadherence by the Elderly," Journal of the American Geriatric Society 5 (1982): 329-33; Jack E. Fincham and Albert I. Wertheimer, "Identifying the Initial Drug-therapy Defaulter," Patient Counseling in Community Pharmacy 3, no. 3 (1985): 12-14; L. A. Shrimp, F. J. Ascione, H. M. Glazer, et al., "Potential Medication-Related Problems in Noninstitutionalized Elderly," Drug Intelligence and Clinical Pharmacy 19 (1985): 766-72.

6. Ruth Faden, Catherine Becker, Carol Lewis, et al, "Disclosure of Information to Patients in Medical Care," Medical Care (1981): 718-33.

7. Louis Harris and Associates, "Views of Informed Consent and Decisionmaking: Parallel Surveys of Physicians and the Public," in Making Health Care Decisions, vol. 2 (Washington, D.C.: Government Printing Office, 1982).

8. Howard Waitzkin, "Doctor-Patient Communication: Clinical Implications of Social Scientific Research," JAMA 252 (1984): 2441-446.

9. D.B. Worthen, "Prescribing Influences: An Overview," British Journal of Medical Education 7 (1974): 109.

10. John Lilja, "How Physicians Choose Their Drugs," Social and Medicine 10 (1976): 363-65.

11. "Pharmacists Rank First in Poll," American Pharmacy, n.s. 28, no. 1 (1988): 2; see also Leon E. Cosler, Richard M. Schulz, H. John Baldwin, et al., "Consumer Preference for Personal Drug Information Source: Relationship to Perceived Importance of Drug Class," Drug Intelligence and Clinical Pharmacy 20 (1986): 138-42.

12. Robert M. Veatch, "Pharmacist's Role in Enlisting Drug Compliance," US. Pharmacist 7, no. 11 (1982): 90-94.

13. Talcott Parsons, The Social System (New York: Free Press, 1951); Conrad, "Noncompliant Patient."

14. David B. Brushwood and Larry M. Simonsmeier, "Drug Information for Patients: Duties of the Manufacturer, Pharmacist, Physician, and Hospital," Journal of Legal Medicine 7 (1986): 279-340.

15. Norman V Carroll and Jean P. Gagnon, "The Relationship between Patient Variables and the Frequency of Pharmacist Counseling," Drug Intelligence and Clinical Pharmacy 17, no. 9 (1983): 648-52.
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Author:Schulz, Richard M.; Brushwood, David B.
Publication:The Hastings Center Report
Date:Jan 1, 1991
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