Life, death and perfectionism

Lately, for various reasons, I've been thinking a lot about mistakes. I've always been a perfectionist, I don't think I know any pharmacists who aren't. But in recent years I have been trying to move towards a healthier form of attention to detail, which is tricky because a step away from perfectionism tends to swerve into embracing mediocrity (of the 'oh **** it I can't be bothered' variety). This healthy version is about recognising and accepting that there are limits to what I can do (such as the time available) and that if and when I make a mistake, I do my best to learn from it. That's how I explain it to colleagues at the beginning of their careers awho are struggling with their mental health in the face of all-consuming perfectionism. For myself I understand these as practical steps on the path of growing in humility.

So what happens when you've made a mistake that has serious consequences (or has contributed to serious harm, because these things are never straighforward) but by the time you find out about it, the consequences have already happened, there is nothing you can do about them, and your learning is limited because you don't know how or why the error occurred. How do you move away from perfectionism when you know that your work can have life and death consequences? How do you learn from a mistake when you know nothing about it except that it happened? When you don't even know what the consequences were because it was part of a chain of errors? How do you not veer off into finding a job with no direct impact on real people (or possibly, retiring to a remote cave)? 

On one level, the answer to these and many other questions is that I have no idea: I don't know how to live with this, I don't know how to move on from this. On the other hand, humility (I am fragile, limited and human and will make mistakes) and the knowledge that the truth undoubtedly does set us free, is absolutely what makes this possible. Loving truth means co-operating with an investigation. It means knowing that the truth is not just important for me but for those of my colleagues who were involved in the same chain of events and for our patients, past, present and future and their families. Embracing humility means not just the part about making mistakes, it may also mean recognising that I am good at what I do and therefore hiding in a cave is not the answer to one mistake. It means accepting that I may never know exactly what happened. And this faith perspective also involves trust and patience and generosity and forgiveness and prayer and no doubt a lot more. Maybe there will be no work-related learning point. Maybe my learning point is: grow in virtue

Whose conscience is it anyway?

I was browsing my September issue of Regula+e, published by the General Pharmaceutical Council, which is the regulatory body for pharmacies, pharmacists and pharmacy technicians, when I came across this article about a pharmacist who had had conditions placed on his practice, by the Fitness to Practise (FtP) committee, for 'imposing his beliefs on patients' (pp24-25).

The pharmacist, during the course of supplying the morning after pill (EHC), told a patient that it was "a chemical abortion, was ending a life, and that this would be on her conscience". The patient was shocked and felt "rotten and horrible". He did not give her the option to go to another pharmacy.

Recently I blogged, among other things, about the weirdness of the fact that while pharmacists do not have to supply EHC, they do have to tell the patient where they can obtain it. This pharmacist didn't tell his patient where they could get EHC, because he did not decline the supply. Yes, apparently he was in the habit of giving what the FtP committee deem 'an embarrassing and distressing lecture' and then giving the patient the morning after pill anyway.

 

There seems to be a whole lot of weird stuff going on here. The FtP committee, for their part, merely have to judge whether a pharmacist has breached the code of ethics and, if so, whether conditions should be imposed or the individual removed from the register, so I'm going to ignore them. It's the behaviour of the pharmacist in question which puzzles me. If it was for moral or religious reasons that the pharmacist gave these speeches to his patients, why did he then supply EHC? What was he hoping to achieve? Was he trying to absolutely prevent evil (ie the patient does not terminate her pregnancy) or just avoid co-operating (the patient gets upset and goes to another pharmacy instead). But if the latter, why did he then supply? It is a mystery to me (although I recogise that I don't have all of the information about the case). And then there is the patient, who reported the pharmacist because he made her feel "rotten and horrible". I'm not saying the pharmacist shouldn't have been investigated, as his actions come across as a bit odd, to say the least: was this his usual manner of advising patients? But as taking the morning after pill causes side effects of headache, nausea, abdominal pain, bleeding and fatigue (very commonly), and dizziness, diarrhoea and vomiting (commonly), the 'rotten and horrible' feeling was somewhat inevitable, if only on a physical level.

 

Whether you, healthcare professional, go with a straight refusal to supply or a slightly more in depth explanation as to why not, or an attempt to engage the patient in discussion as to the rights or wrongs of EHC (or whatever other substance), do so with charity and professionalism! Haranguing the inidividual is unlikely to achieve anything, and following the harangue with supply even less.

 

Interestingly, one of the conditions imposed is that the pharmacist is not to supply EHC in the future. Sounds like good news all round.

 

PS My viewing stats passed the 10,000 mark this week. The list of referring sites may suggest to me that a lot of these views are not real people, but to those actual people who are reading: thank you :-)

In co-operating with evil, where is the line between reality and paranoia?

Yesterday, my brother Andy* and his girlfriend sat down and filled out a mortgage application. Every so often I was asked my opinion about what I thought certain questions were getting at. I did my best to answer them but mostly, given my total ignorance of mortgages, credit cards and money in general, I pointed them in the direction of more reliable answers. I found myself wondering whether I should refuse outright, be rather more non-comittal or launch into a lecture on how co-habitation is not in God's Plan for them, despite the fact that my big-sisterly-omniscience apparently doesn't extend to morals. Andy and Gertrude** plan never to marry (G wouldn't mind if A insisted, I am told, but A is against it) or have children (A would secretly like to but G is vehemently against) and wish to buy a house together so that they can live happily ever after. My other brother, Chris, married Adele*** earlier this year, and prior to this they had been cohabiting for two years in the house they bought together. Now, when Chris told me the two of them were moving in together I expressed my concern and talked about it with him. He was unreceptive, but there was no animosity. Chris and Andy are extremely different in their openness to different ideas, and Chris at least has some basic appreciation for Christian morals. It was worth a try. With Andy there would be no point.

This issue of what counts as co-operation has been on my mind for some time, and I have a tentative plan to follow up my post on healthcare professionals and the law with one on conscience. Here's the deal: Pharmacists have a conscience clause in our Code of Ethics. We can refuse to do something if it is against our moral or religious beliefs. However we must "make sure that if your religious or moral beliefs prevent you from providing a service, you tell the relevant people or authorities and refer patients and the public to other providers". In general, among pharmacists, it is agreed that a conscience clause is a good idea because healthcare professionals constantly have to make difficult decisions about what the best course of action may be. However, the fact that we have to refer the patient to another provider rather makes a nonsense of it: I won't give you the morning after pill but my colleague here/over the road will.

 

I often have conversations with people about how we should handle these ethical dilemmas. For practical purposes I think it is virtually impossible for a Catholic pharmacist to work in community pharmacy (ie a shop) because although 'Emergency Hormonal Contraception' is not an essential service under the NHS community pharmacy contract, it is locally commissioned by PCTs and unless you have the luxury of owning your own pharmacy its unlikely that you would be in a position to say that the pharmacy won't have anything to do with it, and in any case you would still have to tell the person where to access said service. In hospital pharmacy it is a bit easier to pick and choose what field you work in. Most hospitals do not supply contraceptives to in-patients (for obvious reasons), but if a patient is usually takes hormonal contraceptives, you still need to clinically check that prescription. So then what? Is clinically checking when you aren't going to supply a problem? Even if you work in geriatric medicine there is still the dispensary slot, the on-call time when you can't hand over to a colleague. Leaving scripts to one side for other pharmacists to handle is practically a hanging offence. One friend and I were shocked to hear that a consultant simply passes over the ethically problematic patients. For us, that is not how it works. Some people would say they wouldn't dispense Viagra, in case the person was not married, or having an affair, or other immoral behaviour...but surely there comes a point when you have to give someone the benefit of the doubt. What if the person is married and erectile dysfunction is placing a huge strain on their relationship? How far can we go down this line of thought: should we even be working in the NHS?

 

What should we be doing as Catholic pharmacists or other healthcare professionals? Where should we go and work? I don't think the answer is for us to seek out fields of healthcare without ethical dilemmas, because that would also limit our opportunity to transform all of the temporal order which is in contrast to the Gospel (always supposing such fields exist). And I think we definitely need Catholic healthcare professionals. Must we just accept that our career options will be limited, our colleagues will mistrust or despise us and that we end up doing an unfulfilling job because we need to provide for a family?

 

Answers on postcard, please.

 

*Not his real name; if I use a psuedonym myself I'm hardly going to reveal his identity.

**Obviously not her real name, but follows a pleasing pattern known only to myself.

***Likewise.