Medical Ethics and Law Flashcards

A pharmacist has a conscientious objection to dispensing emergency contraception. A patient presents at 11:30 PM — the sole pharmacy open within 60 km — requesting Plan B following a sexual assault. No other pharmacist is reachable. Which course of action best reflects the pharmacist's overriding ethical and legal obligations under Canadian pharmacy law?

Answer: Dispense the medication, as the duty of care and non-abandonment principle supersede conscientious objection when no alternative access exists and delay would cause harm

While Canadian pharmacy regulations protect conscientious objection, they impose an absolute condition: the pharmacist must ensure the patient retains timely access to care. When no alternative provider is accessible and a delay would result in harm (reduced efficacy of emergency contraception is time-sensitive), the duty of non-abandonment overrides the right to object. Provincial colleges (e.g., OCP, CPBC) explicitly state objecting pharmacists must either transfer care or, when transfer is impossible, dispense. Option A abandons the patient without ensuring access; options C and D do not resolve the access problem.

A 15-year-old presents a valid prescription for combined oral contraceptives and explicitly requests that no information be shared with her parents, stating she fears a violent reaction at home. She demonstrates clear understanding of the medication, its risks, and alternatives. Under Canadian common law and provincial privacy legislation, which principle PRIMARILY governs whether this dispensing can occur without parental consent or disclosure?

Answer: The mature minor doctrine — capacity is assessed individually based on the minor's demonstrated ability to understand and appreciate the nature and consequences of the treatment decision

Canadian common law recognizes the 'mature minor doctrine,' originating from cases like A.C. v. Manitoba (2009, SCC). Consent capacity is not determined by age alone but by whether the individual understands the nature of the treatment, its risks, benefits, and alternatives, and can appreciate the consequences. A 15-year-old who demonstrates this capacity can consent independently. Provincial privacy legislation (e.g., PHIPA in Ontario) similarly protects health information of capable minors from parental access. The age of majority governs civil contracts, not health consent. Parens patriae applies when a minor lacks capacity or is endangered, not as a default barrier.

A hospital pharmacist receives an institutional directive to perform automatic generic substitution for all brand-name cardiovascular medications to reduce formulary costs, without requiring individual prescriber notification. For one patient on a narrow-therapeutic-index drug (digoxin), the pharmacist has clinical concerns that the specific generic's bioavailability profile differs meaningfully from the brand. Management insists the policy applies uniformly. What is the pharmacist's primary obligation?

Answer: Notify the prescribing physician of the substitution and the specific clinical concern before dispensing, as the fiduciary duty and standard of practice require pharmacist judgment on therapeutic equivalence for narrow-therapeutic-index drugs

Pharmacists bear an independent professional and fiduciary duty to each patient — this duty cannot be delegated to institutional policy. For narrow-therapeutic-index drugs like digoxin, automatic substitution carries documented risks of toxicity or subtherapeutic levels due to inter-product bioavailability variation. Canadian pharmacy standards of practice (e.g., NAPRA Model Standards) require pharmacists to exercise clinical judgment on therapeutic appropriateness and to communicate clinically significant concerns to prescribers. Institutional cost policies do not override this duty. Filing an incident report (B) is insufficient if the pharmacist proceeds with a clinically questionable substitution without prescriber awareness. Reporting to the college (D) may be appropriate later but is not the immediate obligation.

A patient with a history of bipolar I disorder, currently stable on lithium, confides to the pharmacist during a medication review that they have been intentionally not taking their doses and quietly accumulating tablets 'just in case things get bad.' They deny any specific plan or timeline but appear dysphoric. They make no threat toward any identifiable third party. Which response best reflects the correct application of confidentiality exceptions under Canadian law and pharmacy ethical standards?

Answer: Use clinical judgment to assess the seriousness, credibility, and imminence of self-harm risk; if the risk is assessed as serious and credible, disclose the minimum necessary information to the patient's physician and/or emergency services, after attempting to obtain consent

Canadian privacy legislation (PIPEDA, provincial health privacy acts) permits disclosure without consent to prevent serious and imminent harm to the individual themselves — self-harm is explicitly included. However, this is a permissive exception requiring professional judgment, not an automatic mandatory-reporting trigger. The pharmacist must assess imminence, seriousness, and credibility of the risk. The Tarasoff principle (duty to warn) applies primarily to identifiable third-party threats; however, Canadian frameworks extend disclosure rights to serious self-harm scenarios. The preferred approach is to first attempt to obtain the patient's consent to involve their physician, then escalate if refused and risk is serious. Option A misapplies the third-party threat threshold to a self-harm scenario. Option B overstates mandatory reporting obligations for pharmacists. Option D is insufficiently urgent given the nature of the disclosure.

A pharmacist is processing a medication order for a 79-year-old patient with advanced dementia who has lost decision-making capacity. The patient's validly executed Power of Attorney for Personal Care (POAPC) instructs comfort measures only and formally declines a newly prescribed course of IV meropenem for sepsis secondary to aspiration pneumonia. The attending intensivist believes the antibiotic is in the patient's best medical interest and pressures the pharmacy to proceed. Who holds the legal authority to make this treatment decision?

Answer: The Power of Attorney for Personal Care, provided the refusal reflects the patient's previously expressed wishes or — absent those — a reasonable assessment of best interests; the physician may apply to the Consent and Capacity Board if the decision is disputed

Under provincial substitute decision-making legislation (e.g., Ontario's Health Care Consent Act, BC's Representation Agreement Act), a validly appointed POAPC has legal authority to make treatment decisions for an incapable patient. The substitute decision-maker must apply a hierarchy: (1) the patient's prior capable wishes, then (2) best interests. The physician does not hold override authority — they must comply or apply to the Consent and Capacity Board (or equivalent provincial tribunal) to challenge the decision. The ethics committee may provide guidance but has no binding legal authority. Courts under parens patriae intervene when no substitute decision-maker exists or is disputing capacity, not as a routine requirement for refusal of treatment. The pharmacist should not dispense treatment that has been lawfully refused by the authorized substitute decision-maker.

A community pharmacist dispenses methotrexate 20 mg once weekly (an off-label dose above the standard 7.5–15 mg range) for a patient with refractory psoriatic arthritis. The prescription comes from a rheumatologist with whom the pharmacist has a professional relationship; the diagnosis is not written on the prescription. The pharmacist is aware the dose is high but finds supporting literature and does not contact the prescriber. Six weeks later the patient is hospitalized with methotrexate-induced hepatotoxicity. In assessing the pharmacist's potential professional and legal liability, which doctrine is the court MOST likely to apply?

Answer: The professional standard of care — whether a reasonably competent pharmacist in comparable circumstances would have sought prescriber clarification before dispensing an atypical dose of a high-risk drug

Canadian tort law assesses pharmacist liability through the professional standard of care: what would a reasonably competent pharmacist have done in the same circumstances? Methotrexate is a high-alert medication with a narrow therapeutic margin; an above-range dose without a documented diagnosis is a clear trigger for prescriber clarification. Failure to do so likely falls below the standard of care, regardless of whether the dose has literature support. Negligence per se (A) applies when a statutory duty is violated, not merely an off-label use. The learned intermediary doctrine (C) primarily shields drug manufacturers from liability through the prescribing physician, and does not eliminate the pharmacist's independent professional duty of care. Res ipsa loquitur (D) applies when negligence is self-evident from the nature of the event alone — adverse drug reactions do not inherently meet this threshold.