Prepared by: Wafaa Shwaiky. RPH

Introduction:
For thousands of years, ethics have been recognized as an essential requirement for any profession. The ancient codes of ethics have to some extent stressed this requirement.
The Western medical code of ethics have evolved from the ancient Hippocratic Oath and western principles of gentlemanly honor. Standards of professional behavior were codified in the late17th century and officially adopted by medical associations as early as the mid-19th century.

The Islamic medical ethics are primarily based on the Qur'anic ethics which stand out a perfect model for all mankind, all professions, and in all time.

The origins of medical and research ethics are examined below:

Hippocratic Oath (400 BC)
Hippocrates (Born in Greece 460 BC) is known as the Father of Medicine. He founded a medical school and developed an Oath of Medical Ethics for physicians to follow.

The Hippocratic Oath has formed the basis of more recent healthcare oaths taken by graduates as they begin their practice.

The chief tenants of this Oath are:

1. Honour the instructors of the medical arts.
2. Pass on the Art only to those bound by the Oath.
3. Practice for the benefit of patients, "do no harm".
4. Avoid deadly medicine or substance to produce abortion
5. Enter homes for the benefit of the patient.
6. Abstain from mischief and corruption.
7. Respects the Doctor-patient confidential relationship.

Thomas Percival (1740-1804)
An English physician established in 1794 a code of medical ethics for physicians that were adopted by American doctors and later by the American Medical Association (AMA). This was the first code of ethics to be adopted by a professional organization replacing the variously interpreted ethics of gentlemanly honor and thus providing a standard of behavior for medical professionals.

American Medical Association ( AMA) Code of Ethics (1846)
The (1980) version of AMA code of ethics has seven articles, while the updated version (2001) contains nine articles. The additional articles in the current version stress physician’s responsibility, and support of universal access to medical care. In addition, the latest version added all required provisions regarding a commitment to medical education and a responsibility for the improvement of public health. The AMA code has some other features like:

1. The respect of the law.
2. The respect of the patient’s rights.
3. The respect of colleague’s rights.
4. The respect of patient’s privacy and confidentiality.
5. The dedication, competence, and compassion.
6. The honesty and duty to report fraud or deception.
7. The continued education, study, and consultation with other professionals.
8. The freedom of association and environment in the practice of the Art.
9. The responsibility to make efforts to improve the community

Nuremberg Code (1947)
Nuremberg code is a result of the post World War II (WWII) trial of a group of Nazi doctors, for crimes against humanity committed in the name of research. This code represents the starting point in discussions about the ethical treatment of human subjects.

German doctors, performed macabre medical experiments under the disguise of scientific research in Nazi concentration camps where prisoners were used without concern for their welfare.

The Nuremberg Code is a set of ten principles outlining the ethics of medical research and ensuring the rights of human subjects.

The principles include the following:

1. Informed, voluntary consent.
2. Research must be purposeful and necessary for the benefit of society.
3. Research must be based on animal studies or other rational justification
4. Avoidance and protection from injury, and unnecessary physical and mental suffering
5. Risks to the subject shall not be greater than the humanitarian importance of the problem
6. Investigators must be scientifically qualified.
7. Subject may terminate the experiment at any time.

Declaration of Geneva (1948)
The World Medical Association adopted this oath after the atrocities committed in the name of research in Nazi concentration camps. Key features of this code are:

Service to humanity, respect and gratitude for instructors, conscience and dignity in the practice of the Art, dutiful attention to the health of the patient, colleagues and traditions of the Art , practice in accordance with the laws of humanity, respect for human life from conception , and duty takes precedence over racial, religious, political or social prejudices.

Declaration of Helsinki (1964)
The first publication of this declaration was in 1964, as a response to unethical medical experiments of the Nazis during WWII. It has been revised several time since 1964, the latest revision of the document was in 2000 and states the following principles :

• The well being of the human subject should take precedence over the interest of science 
  and society.
• The doctor should only act in the patients best interest and that the health of the patient is 
  the first concern.

Many of declaration’s principles are incorporated in national research regulations. On the other hand the revised document discusses the use of placebo, recommends that ethics committees have the obligation to monitor ongoing trials, and requires that researchers disclose to subjects details of funding and possible conflicts of interest. Finally, there is a recommendation that publishers decline studies not carried out in accordance with the declaration.

Islamic medical Ethics 
The Qur'anic ethics stand out as a perfect model for all mankind, all professions, and all time. It guidelines for mankind’s behaviour and attitude, both at the personal and professional levels.

This standard of moral and ethical values should guide the Muslim health care practitioners in their private life and while conducting their professional life as well.

Muslim pharmacists must believe in God and in Islamic teachings and practice, both in private and public life. They must be grateful to their parents, teachers, and elders. They should be humble, modest, kind, merciful, patient, and tolerant, and they must follow the paths of the righteous and always seek God's support.

Pharmacists equipped with the above-listed virtues are capable of complying with the following professional requirements needed:

1- Knowledge: Muslim pharmacists must acquire, maintain, abreast of current medical knowledge, and continuously improve their skills.  God makes it clear in the Qur'an" … Say: Are those equal, those who know and those who do not know?… "  Qur'an: 39/9.

Therefore the believer is encouraged to always seek knowledge.

"... Say: O my Lord. Advance me in knowledge." Qur'an: 20/114.

2- Respect of the law: Muslim pharmacists must respect law, order and legal rules regulating their profession. The following verse reflect this concept "Oh you who believe: Obey God and obey the Apostle, and those charged with authority among you..." Qur'an: 4/59.

3- Professional commitment to the health and well-being of patients life:  As a health care providers, pharmacists must understand the importance of patient’s health and well-being. God states this issue clearly in the Qur’an in the following verse:  " ... Whoever kills a human being not in lieu of another human being nor because of mischief on earth, it is as if he has killed all mankind; and whoever saves the life of a human being, it is as if he has saved the life of all mankind..." Qur'an: 5/32.

4- Pharmaceutical advices: Pharmacists should offer all pharmaceutical advices needed with consideration for patient educational level and age.

5- Communication: Pharmacist must adopt an appropriate manner of communication with patients and colleagues.

6- Patient confidentiality: Pharmacists must protect the patient's confidentiality, reflecting God's description of the believers: "Those who faithfully keep their trusts and their covenants." Qur'an: 23/8.

Written By: Hanan Khalaf. RPH

Clinical pharmacy can be defined as that area of practice within the health organization in which the pharmacist, through his work within an interdisciplinary team, apply his clinical judgment to assure safe and appropriate use of drugs. This division of pharmacy practice requires specialized education within the pharmacy curricula and structured training to candidates in order to achieve the required goal in their practice.

Based on the above definition, the clinical pharmacist, who is working in direct patient care areas, is usually involved in medical rounds with the other health care professionals and participates in:

1. Obtaining patient medication histories.

2. Selecting the most appropriate therapeutic agent and monitor the therapy.

3. Answering drug information queries to physicians & other health professionals.

4. Patient education and counseling.

5. Providing in-service education for physicians, nurses, and other health professionals.

In addition to the above mentioned functions, several other functions are being introduced in the field of clinical pharmacy, but rather in a specialized form. Examples of these are:

1. Clinical pharmacokinetics. 

2. Total parenteral nutrition services.

3. Clinical toxicology practicing in formal poison information centers.

4. Clinical drug investigations.

5. Formal drug therapy consultations.

6. Participation in medication use evaluation.

7. Specialized clinical pharmacy practice in various medical fields like oncology, nephrology, surgery, pediatrics, intensive care, and others. Such specialization requires specialized training under what is called residency programs and others.

The Pharmaceutical code of ethics is generally evolved from the medical code of ethics. They include guidelines for the pharmacist’s behaviour and attitude both at the personal and professional levels. The same standard of moral and ethical values should guide the pharmacists in their private life and while conducting their professional business as well.

Any lack of moral values in private life may lead to a lack in trust at the professional level, even with the highest professional or technical qualifications.

We can categorize the pharmacists’ moral values into three groups based on their professional relationship as the following:

A. The Pharmacist- Patient relationship.
B. The Pharmacist- Colleagues relationship.
C. The pharmacist’s self-improvement at the professional level.

A. The Pharmacist- Patient relationship:

This relationship is considered as a covenant, which means that the pharmacists have moral obligations in response to the trust received from society, based on that, pharmacist promises to: 

1. Respect the professional relationship with the patient and act with integrity compassion and honesty.
2. Help patients achieve optimum benefit from their medications.
3. Provide a competent care to the patient.
4. Respect the patient needs, values and dignity.
5. Support the patient's right to receive competent and ethical health care.
6. Support the patient’s right to make his choice about pharmacy care.
7. Provide information to the patient in an understandable way.
8. Aid the patient to be an active participant in his pharmaceutical care.
9. Provide pharmacy care with consideration of the patient’s personal privacy, and maintain practices that protect patient confidentiality.
10. Ensure continuity of care under any circumstances.
11. Protect the patient's right of confidentiality.
12. Maintain the patient’s trust.
13. Avoid discriminatory practices and behavior.

B- The Pharmacist- Colleagues relationship: 

1. All pharmacists must accept responsibility to work with colleagues, health care professionals, and others, to promote safe and effective pharmacy care.
2. Pharmacists should first consider the welfare of the patient when they suspect incompetence or unethical conduct by a health care professional. They should engage in direct discussion with the health care professional involved, if a situation can be resolved without peril to the patient.
3. Pharmacists must honour the teamwork.

C- The pharmacist’s self Improvement at the professional level. 

1. Each pharmacist from his site must endeavour to ensure that the practice environment contributes to safe and effective pharmacy care.
2. The pharmacist must commit to lifelong learning designed to maintain relevant knowledge and skills.