'Islands' and 'doctor's tool': the ethical significance of isolation and subordination in UK community pharmacy.

Empirical ethics research is increasingly valued in offering insights into how ethical problems and decision-making occur in healthcare. In this article, the findings of a qualitative study of the ethical problems and decision-making of UK community pharmacists are presented, and it is argued that the identified themes of pharmacists' relative isolation from others and their subordination to doctors are ethically significant. Semi-structured interviews were conducted with 23 community pharmacists in England, UK. Analysis of interviews revealed that isolation involved separation of pharmacists from their peers, other healthcare professionals, patients and customers. Such isolation is argued to be inimical to ethical practice - impeding ethical discourse as understood by Habermas, resulting in a form of anomie that inhibits the transmission of professional values, leading to a lack of proximity between pharmacist and patient or customer that may impede ethical relationships and resulting, psychologically, in less ethical concern for those who are less close. Pharmacists' subordination to doctors not only precipitated some ethical problems but also allowed some pharmacists to shift ethical responsibility to a prescribing doctor, as in the case of emergency hormonal contraception. The emergence of atrocity stories further supports a culture of subordination that may cause ethical problems. The study has implications for community pharmacy practice in terms of supervision issues, developments such as prescribing responsibilities and how ethical values can be taught and communicated. The potential for isolation and subordination in other healthcare professions, and resultant ethical problems, may also need to be addressed and researched.